The Domino Effect on Intergenerational Relationships

1. The Domino Effect on Intergenerational Relationships A Scottish Collaborative Forum at 10: The importance of good relationships Grand Central Hotel, Glasgow 13 May 2019 George Hosking, CEO, WAVE Trust

2. Are mental health issues passedfrom generation to generation? Exploring the intergenerational persistence of mental health: Evidence from three generations (Johnston, Schurer and Shields, 2013) • Uses 1970 British Cohort Study data to quantify intergenerational persistence of mental health • ‘We find a strong and significant intergenerational correlation that is robust’ • Strength of correlation increases with age of child exposure to maternal mental health problems • Inter-generational correlation stronger through mothers than fathers • Also stronger for mother-daughter than mother-son comparisons • Grandmother mental health significantly related to grandchild mental health

3. What causes the domino effect? • Genetics? • Adverse Childhood Experiences? • Environmental pressures?

4. Genetics • Research comparing large population numbers found evidence that autism, ADHD, clinical depression, bipolar disorder and schizophrenia may have common genetic risk factors • Largest available familial study observed a strong heritability effect for Schizophrenia and Bipolar Disorder, but with genetic effect less than half that of environmental factors (Geoffroy at al, 2013) • Many diagnoses of ADHD are actually of children with FASD – Foetal Alcohol Spectrum Disorder • If mental illness has persisted in a family over generations this does not mean it is genetic • Even if there is a genetic component, it may need particular environmental conditions to be triggered

5. Genetics • WHO: Many relatively simple models of the nature of mental disorders, their causes and their neural substrates now appear quite frayed • Gone are explanations based on family history, abnormal levels of neurotransmitters, or notion there is a single gene that causes any mental disorder or determines any behavioural variant • Concept of causative gene has been replaced by that of genetic complexity, in which multiple genes act in concert with non-genetic factors to produce risk • National Institute of Mental Health (NIMH): ‘many mental disorders are caused by a combination of biological, environmental, psychological, and genetic factors’

6. I Adverse Childhood Experiences (ACEs)

7. Impact of ACEs (English ACE study)

8. ACE impacts on Mental Health – 1 • Anxiety disorders (Deventer et al, 2013, Mersky et al, 2013) • Behavioural problems • ADHD diagnosis in middle childhood (Brown et al, 2017) • Externalising and internalising behaviours (Hunt et al, 2017) • Bipolar disorder (Anda, Brown et al, 2007);  • Childhood autobiographical memory disturbance (Brown et al, 2007) • Chronic mental health problems (NHS, 2012) • Depression (Anda et al 2006, Arnow, 2004, Chapman et al, 2004, Deventer et al, 2013, Schilling et al, 2007, Mersky et al, 2013) • Dissociative amnesia (Brown et al, 2005) • Eating disorders (WHO, 2013)

9. ACE impacts on Mental Health – 2 • Panic reactions, anxiety and hallucinations (Anda, Felitti, Bremner et al, 2006) • Personality disorders (Herman et al, 1989, Zanarini et al, 1997) • Poor adult psychiatric outcomes (Arnow, 2004) • Post-traumatic stress disorder (Scott et al, 2010, Green et al, 2010) • Psychoses (Cutajar et al, 2010) • Rates of prescriptions (Anda et al, 2007, 2008) • Antidepressant, Anxiolytic, Antipsychotic • Mood-stabilising/bipolar medications • Self-harm (WHO, 2013) • Suicide attempts (WHO, 2013) • Uncontrollable anger

10. ACE impacts on Mental Health – 3 • Two categories of ACEs in childhood (out of a possible 10) increased likelihood of anxiety and panic reactions by 70%, depressed affect by 120%, hallucinations by 130% Anda, Felitti, Bremner et al (2006) • Number of ACEs has graded relationship to both lifetime and recent depression • Exposure to ACEs associated with increased risk of depression up to decades after their occurrence • Early recognition of childhood [ACEs] and appropriate intervention important in the prevention of depression throughout the life span Chapman, D.P., Whitfield, C.L., Felitti, V.J. et al (2004)

11. ACE impacts on Mental Health – 4 • Survivors of early maltreatment differ from other individuals with the same psychiatric diagnoses in critical ways (Teicher and Samson, 2013) • Disorders emerge earlier in maltreated individuals • They have greater severity • They occur along with other disorders more frequently • They show less favourable response to treatment

17. Environmental pressures • Studies show relationship between family economic pressures and teenage internalising and externalising problems, including mental health issues (Conger et al, 1994) • Loss or absence of valued resources can produce a variety of emotional responses such as apathy, depression, anger or aggression (Berkowitz 1989, Conger et al, 1984) • These effects are mediated through family arguments over money, disruptions in parent-child relationships and coercive family relationships (Wickrama et al, 2005) • Children in poor families more likely to be born with physical health problems, and to suffer poor nutrition or health care, leading to greater physical illness. Physical illness impacts depression. Also, adversity leads to greater stress which affects biological functioning (Wickrama et al, 2005) • Wickrama sought to show family adversity led to adolescent mental disorder, but did not find this. He did find family adversity increased factors such as school drop outs, teen pregnancy, sexual behaviour and unemployment, and that these factors affected teen mental health.

19. ACE score: learning and behaviour problems

21. Conception to age 2 – Key findings • Children of mothers with mental health issues twice as likely to develop psychiatric disorder • Poor maternal mental health/well-being at 9 months and 3 years strongly associated with poor child behaviour at age 5 • Post-natal depression and other mental illness linked to behavioural disturbance at home, less creative play and greater levels of disturbed or disruptive behaviour at primary school, poor peer relationships, and a decrease in self-control with an increase in aggression

22. Conception to age 2 – Key findings • All Babies Count (NSPCC): in the UK overall, 144,000 babies under a year old live with a parent who has a common mental health problem • The most common issues from a 2-year study of serious case studies were mental ill-health, domestic violence and drug and alcohol misuse • Child abuse has a causal role in most mental health problems, including depression, substance misuse, and anxiety, eating, personality and dissociative disorders (Read et al, 2008)

24. WAVE Age 2 to 18 study ofSevere and Multiple Disadvantage • A four-year research project: • To understand the key transitions and triggers which affect severe and multiple disadvantage • And how systems could provide positive outcomes following these transitions

25. WAVE Age 2 to 18 study – Conclusions • ACEs major causes of later life severe and multiple disadvantage (e.g. homelessness, unemployment, substance abuse, criminality, mental health problems) • Lifelong disadvantage established when children not ‘school ready’ allowed to continue in school without adequate support to catch up • School exclusion major trigger point for downward pathways • Trauma-informed care (e.g. schools, policing) works well where trauma suffered; trauma-informed communities show significantly improved outcomes

26. WAVE Age 2 to 18 study of SMD Key recommendations: First, prevent ACEs before they happen; and If you fail - adopt pedagogical, ACE-aware, trauma-informed systems (schools, social services, health, policing, prison, probation, communities) for all vulnerable citizens, especially children • ‘The most reliable way to produce an adult who is brave and curious and kind and prudent is to ensure that when he is an infant, his hypothalamic-pituitary-adrenal axis functions well. And how do you do that? It is not magic.  • First, as much as possible, you protect him from serious trauma and chronic stress; then, even more important, you provide him with a secure, nurturing relationship with one parent and ideally two’ [Tough 2012, p. 182]

27. Risk situations for babies under 1 year • 0-1 peak age for abuse and neglect in the UK • In the UK 122,000 babies per annum will develop disorganisedattachment • 39,000 babies in the UK have a parent who has experienced domestic violence in the last year • 109,000 babies live with a parent who is a substance misuser • 144,000 babies have a parent with a mental health problem

28. Understanding the infant brain • Works via neurons (brain cells) & synapses (connections) • At birth: 10 trillion synapses - 200 trillion by age 3 • Sculpted: Repeated use hard-wired; superfluous eliminated • Implies very rapid learning via early life experience – - more than 1 million new connections per second • Critical windows of time during which brain hones particular skills or functions; emotional brain in first 18 months

29. Shaped by the carer’sinteraction style • Alan Schore - 10-year immersion in thousands of scientific papers in neurobiology, psychology, infant development “The child’s first relationship, the one with the mother, acts as a template … permanently moulds the individual’s capacity to enter into all later emotional relationships”

30. Shaped by the carer’s interaction style • Infant brain needs time to mature, so … • Baby regulates inner world by aligning emotional state of mind with caregiver • Empathic attunement acts like emotional umbilical chord • Methods: Eye gaze, facial expressions, nonverbal signals

33. Keys: Attunement and Empathy • Lack of attunement means empathy does not develop • Low maternal responsiveness at 10-12 months predicted: • at 1.5 years: aggression, non-compliance, temper tantrums • at 2 years : lower compliance, attention getting, hitting • at 3 years : problems with other children • at 3.5 years: higher coercive behaviour • at 6 years : fighting, stealing

34. How do we prevent ACEs? • Universal risk analysis and support in pregnancy • Further support at time of birth • Ongoing monitoring and support to promote good attunement (leading to secure attachment) from 0-24 months

35. Assessment of Risk • Universal risk assessment at ante-natal stage • Carried out by trained midwives or health visitors (potential GP support) • Check for prior ACEs in parental history (including step-parents) • Parental experience of child maltreatment: measure developed at Kings College London • Other screening tools available but need for special training and adequate resource • Universal assessment at 3 – 6 months • Quality of interaction between mother and baby • Using Video Interaction Guidance/Parent Infant Interaction Observation Scale • Or Spanish analysis of the Parent-Child Psychological Support (PCPS) programme, which runs from 3-15 months

36. Targeted Support • Range of programmes • For parents maltreated in childhood, increased provision of psychological therapies and mental heath support • For domestic violence risk, approaches such as Family Foundations, IRIS, Healthy Relationships, Healthy Babies (For Baby’s Sake) • For substance abuse, Parents Under Pressure or other support methods • For mental health issues and poor attunement, Video Interaction Guidance, Parent-Infant Psychotherapy, Specialist Perinatal Mental Health Support, • Other support programmes include Baby Steps, Minding the Baby, Solihull Approach, Mellow Bumps, Babies, and Parenting

37. Community Component • The goal: community engagement and ownership of commitment to creating healthy, successful lives for children, happy relationships in families • Reducing maltreatment a necessary but not focal part of the positive community goals • Proposed approach – Integration of ‘Trauma-informed Communities’ with ‘Asset Based Community Development’ – both have proven results • Training ‘Community Builders’ • Local assets primary building blocks of sustainable community development • Communities active co-producers in design, planning and implementation • Work done with communities not to them • Community groups have already started trauma-informed communities in Glasgow and Drumchapel

38. Parent Child Psychological Support (PCPS) • Universal programme supporting mothers from baby aged 3 months to 18 months, used very successfully in Dublin, and Spain. Striking improvements in secure vs insecure, and disorganised, attachment • Six visits to a health centre or family centre, with broad range of support: • Standard health visiting (baby’s progress, health, weight, immunisations) • Video support on attunement • Speech and language development • Mother’s own health and well-being • In Dublin: high participation rate by mothers

39. Parent Child Psychological Support (PCPS)

40. Parent Child Psychological Support (PCPS)

42. MMHA Action recommendations • Get in touch before upcoming strategic event or meeting in your area where campaign materials / presentations can feature – or if you have any other ideas for how the campaign can support: info@everyonesbusiness.org.uk • Use our campaign maps to identify the level of specialist perinatal mental health service provision in your area; share this with local decision makers, alongside the reasons why specialist services act as a catalyst for change across the whole pathway • Share your area’s starting point and feature images of the maps on social media (#everyonesbusiness) and within local media to highlight where funding for services is still needed or indeed to celebrate progress to date and inspire other

43. MMHA Action recommendations • Include costs of perinatal mental illness (£8.1 billion UK = £680 million Scotland) and real life stories when explaining to decision makers what your area needs. This combination of winning hearts and minds is a key driver of change • Share models of good practice with decision makers, providers and commissioners in your area. On a national and local level, models of good practice and guidance for specialist perinatal mental health services have been established. (See examples on Maternal Mental Health Alliance website)