Understanding Childhood Mental Health Needs in Care

1. Keeping children’s minds in mind:Mental health needs of children in care

2. Brain and neurobiological development. How might this change the way we think and what we do? How does early adversity and developmental trauma impact upon us as adults? Implications for Court, clinicians and services.

3. These images illustrate the negative impact of neglect on the developing brain. The CT scans on the left are from healthy three year old children with an average head size (50th percentile). The image on the right is from a series of three, three year old children following severe sensory-deprivation neglect in early childhood. Each child’s brain is significantly smaller than average and each has abnormal development of cortex (cortical atrophy) and other abnormalities suggesting abnormal development of the brain. From Perry, B. D. (2002) Childhood experience and the expression of genetic potential: What childhood neglect tells us about nature and nurture. Brain and Mind, 3: 79-100

4. Hypothalamus-Pituitary-Adrenal (HPA) Axis • Complex system controlling reactions to stress. • Linked to release of adrenaline, increased heart rate, blood pressure and cortisol. • Dysregulation/sensitivity if individual has suffered significant abuse (Dozier et al., 2006; Fisher and Stoolmiller, 2008).

5. Orbitofrontal cortex • Executive functioning • Last region to fully develop, implicated in inhibition, self-regulation, emotional recognition • Maltreated children present with reduced grey matter in medial orbitofrontal cortex

6. Polyvagal theory • Evolution of nervous system. • First developed immobilised defensive responses (parasympathetic), then evolved to enable mobilised responses (sympathetic), and final branch regulates physiological state during social interactions. • These responses in children are hierarchical, depending upon the success of more evolved responses.

7. The most important task is to develop a clinically informed framework for understanding: The developmental effects of abuse and neglect. The particular needs of these children. How to best respond both therapeutically and systemically. How might this change the way we think?

8. Intersubjectivity, attunement and mentalization

9. Within a securely attached relationship, repeated mentalisation by the carer results in the child developing a capacity to plan, anticipate and learn to express feelings and thoughts, to regulate emotions and reflect upon experiences. Children who have suffered early trauma have often lacked these experiences, and as such their ability to feel understood and emotional development can be inhibited. Keeping children’s minds in mind…

10. ‘You look tired…’ Keeping their minds in mind…

11. Formulation rather than diagnosis

12. Reason for referral Early history Assessments and diagnoses Current situation James

13. 2000/2003 – NEPS (developmental progress, emotional and behavioural difficulties) 2003 – CAMHS (anxiety) 2005 – Child and Family Psychology (‘emotional issues and attachment needs’) 2007 – CAMHS (anxiety, OCD, paranoia, concentration) Reason for referral

14. Uneventful delivery, no reported problems following birth Mother initially coped well, breast-fed for first 4 ½ months, then developed depression (reluctant to seek help) ‘Domestic disharmony’ Taken into care at 2 ½ years In current foster placement since aged 3 ½ Early history

15. “John presents as a happy, active, sociable little boy…he appeared to settle quite easily into (foster carers’) home. At that point in time he was still wearing nappies and he was inclined to over eat. John did not appear to know when he was hungry or when he was full…anxious when visiting strange houses or places…afraid to go upstairs…would ask (foster carer) to check the wardrobe to make sure his mother was not in it…John has become a secure, confident little boy who has attained all his developmental milestones – physical, psychological, emotional and social.” (2002)

16. “…more angry, explosive outbursts…on two occasions John has tried to choke (foster brother)…frequently threatens to kill (foster brother), (foster carer) and small children…talks about stabbing people…can’t settle at anything…obsessional…paranoid behaviour…poor personal hygiene…difficulty integrating with peers…” (2010)

17. CAMHS - Obsessive compulsive disorder, reactive attachment disorder, sibling rivalry disorder, insulin dependent diabetes, serious social disability (2010) ASD – “…at present, the difficulties observed are not prominent enough to warrant a diagnosis of autistic spectrum disorder.” (2010) OT – “…overall, John’s difficulties are likely to be related to poor body awareness and motor planning skills.” SALT – “Severe language delay.” (2000) IQ – “Average range.” (2005), “Low average range.” (2009), “Borderline” (2012). Assessments and diagnoses

18. The more we can learn and teach others about the neurobiological problems and subsequent behavioural difficulties, the more we can avoid misunderstanding children’s behaviours. Shift the focus away from managing behaviour towards understanding behaviour. Which therapeutic approaches? What could we do differently?

19. Dyadic Developmental Psychotherapy/PACE (Hughes, 2011) Mentalization-Based Treatment for Families (MBT-F) (Bateman and Fonagy, 2012) Video Interaction Guidance (VIG) Specific interventions

21. ‘…the expectation that we can be immersed in suffering and loss daily, and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet.’ (Conrad, 2004) Importance of supporting placements and other professionals

22. ‘No other groups of children and young people in the developed world are more socially or developmentally disadvantaged than children and young people who reside in court-ordered alternate care, and those who are subsequently adopted from care… These populations exert exceptional demands on poorly matched, generic mental health services…’ Tarren-Sweeney and Vetere (2013)

23. ACE Study (Felitti et al., 1998) found that cumulative adverse childhood experiences resulted in a dose-treatment effect upon obesity, diabetes, depression, suicide attempts, heart disease, STDs, cancer, stroke, COPD… Smoking, alcoholism, drug misuse. Early adversity and public health

25. The Hidden Epidemic ‘The knowledge of horrible events periodically intrudes into public awareness but is rarely retained for long. Denial, repression and dissociation operate on a social as well as an individual level.’ Herman (1992)

26. ‘Abuse of children has excited periodic waves of sympathy, each rising to a high pitch, and then curiously subsiding until the next period of excitation.’ Radbill (1968)

27. So, what do we do? ‘To the degree that we do not figure out how to integrate this knowledge into everyday clinical practice, we contribute to the problem by authenticating as biomedical disease that which is actually the somatic inscription of life experience on to the human body and brain.’ Felitti (2013)

28. “The development of most adopted children progresses smoothly. However, if concerns do emerge, and their families seek out help from child and adolescent mental health services, it often appears as if the children’s problems are linked to their difficult start in life. Therapeutic services offered…need to be aware of this and adapt their services accordingly, paying particular attention to the specific vulnerabilities that adopted children and their families may have.” Muller et al. (2012) Implications, challenges and opportunities

29. One of the most important issues to confront in promoting better outcomes for abused and neglected children is a mismatch between three timeframes: Those of the developing child, those of the courts, and those of the local authority. “Studies that explored the consequences of professional decision-making in neglectful and/or abusive families all found that a high proportion of maltreated children are left in very damaging circumstances with inadequate action being taken to safeguard them, and with adverse consequences for their health and development.” Brown & Ward, 2012 (citing Farmer and Lutman, 2012; Wade et al., 2011; Ward, Brown & Westlake, 2012) Decision-making within the child’s timeframe

30. To support children in care practitioners need to know what effective, evidence-based treatment and support options are available in their community. Carer support and training has been found to be a key strategy to improve outcomes for foster children (Leve et al., 2012). Importance of a system-level focus on safety, permanency and well-being. Linking child welfare workers with evidence-based practices

31. “The research is clear that the experience of abuse and neglect leaves a particular traumatic fingerprint on the development of children that cannot be ignored if the child welfare system is to meaningfully improve the life trajectories of maltreated children, not merely keep them safe from harm.” Bryan Samuels (2011), Commissioner of the Administration on Children, Youth and Families, U.S. House of Representatives

33. Thank you liam.shine@hse.ie