Combating Adverse Childhood Experiences through Resilience Based Interventions
This presentation instructs parents, clinicians and the greater community on the ways in which they can help build resilience in children through attachment and play-based exercises, and address how these exercises and interventions help build adaptive and integrated brain architecture in young children.
Dr. Eraina Schauss: So I'm a professor of clinical mental health counseling at the University of Memphis. And one of the first things that people always ask me is what is clinical mental health counseling? Is that some sort of version of psychology or social work? So it's actually a form of applied psychology. What that means is that we take research, scientific research like the research that Dr. Levitt just presented on and we take that research and we translate it into evidence-based practices, so evidence-based clinical intervention.
So what does that mean? It means that on a day-to-day basis we're training clinicians; we're training therapists. And why therapy is so important and what all of the volume of research are able to show and tell us now is that therapy essentially changes the structure and the function of the brain. So counselors, clinicians, psychotherapists, we're the people in the trenches. We're the people providing the services. We're the people, the vessels, the safe containers, the places where you can process all of the trauma, all of the sadness, all of the grief, all of your stories and build a coherent narrative.
Now, I have this picture here of a brain in puzzle pieces. And that's essentially what a lot of clients come in and present with. They don't really understand how their lives got to be where they are. It's all about a series of different events that brought them to the place that they are today. So counseling, in essence, is a strengths and resilience focused type work. So it's building the pieces of the puzzle. And taking the resilience that each individual has and presents with, and appreciating what got them there today, and helping to foster strengths, foster growth, and in turn, changing the structure of your brain.
So what it does, and by co-constructing a new narrative through counseling, it creates an evolving blueprint for the experience that modifies someone's self-image, it aids in affect regulation, and it serves as a guide for new neural circuits and positive behavior. And what it also does is it creates awareness. And when you're talking about or when you're thinking about adverse childhood experiences, awareness is key to change. Awareness is a catalyst for change. So what are these adverse childhood experiences that I'm talking about?
So in 1995, the Center for Disease Control and Kaiser Permanente partnered what we know as now the ACE Study. And what they did was they recruited 17, or a little over 17,000 individuals. And they asked them questions during their annual physical. So they asked them things like, about their lives before they were 18 years old. So they wanted to know things about neglect and family trauma and their earliest childhood experiences about relationships. So all of these domains that you see up here, these are the 10 questions from the original ACE questionnaire.
So for each answer that you answered yes, so if you grew up in a house where there was substance abuse, and maybe that person suffered from a mental illness, or another person in your family. And then you suffer from emotional neglect because your parent or your caregiver or whoever it is isn't able to be present, be attuned, be responsive to your needs. And also you grew up in a house with divorce. That's four ACEs, it's a score of four ACEs. And what they're able to show is that there's a dose response to the relationship.
So the higher your ACE score, the more likely you're to have worse physical ailments as well as mental health conditions. So this is the ACE pyramid here. And what you're able to see here is that these adverse childhood experiences lead to disrupted neural development, lead to social and emotional cognitive impairment, lead to adoption of health risk behaviors, and then lead to all of the things that Dr. Levitt just presented on about disease and disability and social problems. Ultimately putting you at risk for all kinds of health ailments, so you have COPD, you have depression, you have diabetes, you have hypertension ultimately leading to an early death.
So what we know concretely, through the ACE Study, is that these earliest experiences, these experiences that you have as a child, you bring with them throughout the course of your lifespan, ultimately leading you up that pyramid. And the more ACEs you have, the more likely you are to go pretty quickly up that pyramid. So in 2014, the Shelby County Task Force commissioned an ACE Study to look at how ACEs or how prevalent ACEs are in our community.
So what they were able to find, their findings really replicated what was found with the original ACE Study. More than half of our population has had at least one ACE, and then one in eight people had four or more ACEs. And those people who had 4 or more ACEs where 2 time more likely to be unemployed, 3 times more likely to be problem drinkers, 4 times more likely to be smokers, 6 times more likely to be diagnosed with depression, 7 times more likely to have had a sexually transmitted infection, and 20 times more likely to have attempted suicide.
So with that, the ACE task force developed the ACE Awareness Foundation here in Memphis, and the Universal Parenting Places, the two pilot centers here in town. And I feel very grateful and fortunate to be a part of the Universal Parenting Places. I developed their clinical model and trained their clinical staff on how do we work to combat ACEs? How do we fight ACEs in our community? And how do we ensure that future generations don't have these types of statistics.
So, the early trauma and the neurobiology behind it. So, much of what we know today about the neurobiology of early childhood trauma comes out of the Romanian orphanage studies. So during the Ceausescu regime, there was very little access to any kinds of...actually there was no access to any kind of birth control, any kind of abortion. The population skyrocketed. The country was impoverished and they weren't able to take care of the children.
So what happened was the state set up these orphanages. So when the regime fell in 1989, the world found out that there were 170,000 children in orphanages in Romania. That's a staggering statistic. And what these studies, what came out of these studies was that we're able to see the impact that severe trauma and severe social deprivation has on the brain. So these children were confined to their cribs for days. And what do you see when things like that happen?
They have no way of self-soothing so these types of behaviors that you see in clinical practice where it's the head-banging or the rocking, try to...it's a way for the child's body to try and offer some ability to self-soothe. So what we know from the early intervention studies or the Romanian orphanage early intervention studies was spearheaded by Charles Nelson out of Harvard in 2000. And what they did was they actually set up the first foster care system in the country.
And they recruited 136 children from the orphanages, across six orphanages in Bucharest. And what they did was they examined the function of the brain. So these children were given brain scans to monitor the development of white matter in the brain. And white matter in the brain is the part of the brain that helps your neurons communicate. And typically, in a normal child, there's a linear increase in the speed of...it's in the speed of your cognitive abilities, but that's due to the white matter.
That white matter will increase over time as you develop. What we were able to see through this work with the Bucharest Early Intervention Project was that the children who remained in the orphanages, it stopped the growth of white matter. It completely stopped. And the children that were then placed in the foster care homes, they were actually able to regrow and regenerate that white matter. So these children who were able to build a secure attachment with their foster parent had increased brain activity at age four, and then again at age eight.
So what we're able to see is this enormous developmental catch-up for these children that were placed in these homes, that they were able to build those relationships and regenerate the brain growth. We were also able to see that children fared better the earlier they got out of the institution. So children under the age of two did much better than the children that were placed in foster homes after the age of two.
So any length of time spent in the orphanages, it reduced the IQ, it increased dramatically children's emotional, psychological, behavioral problems, and a lot of times leading to early death. So, what is attachment and why is it important? So I talked about these children that were put in these foster homes that were able to regenerate or regrow their brain. What is the attachment? What does that mean? What does that look like? Why is that important? Why is the attachment piece so critical?
Does anybody know why attachments are important? Okay.
Dr. Eraina Schauss: Yes, it provides that bonding place, that bonding experience. It provides a place for trust and security. And those attachment bonds that you have really, essentially, are what develops your...it's a template. It's a blueprint for how you attach to people throughout your lifespan. So the earliest experiences that you have, those earliest bonding experiences really are the template or the guide that you have over the course of your lifetime.
And it's interesting when you think about attachments. You form your attachments in the earliest periods of your life, right? So we also know during those earliest, critical periods, that's also the same period that coincides with the most rapid amount of brain growth and brain development. So you can see how attachments really impact brain development. And they have significance in terms of all of the types of relationships and functions that you're able to perform throughout the course of your lifespan.
So when you develop a secure attachment to an individual, it enables you the ability to go out, to explore, which comes to my next slide. How do you foster a secure attachment? So Dan Siegel at UCLA, he's written prolifically a lot of New York Times bestsellers, but one of the books that I really love of his is "The Whole Brain Child". And what he talks about is how to develop a secure attachment relationship.
So children need to be seen. So what does that mean? Perceiving them deeply and empathically, so it's getting them, but it's more than that. It's being attuned to them. It's being just plugged in. It means that they're being seen, but they're also being felt. Be safe, so avoiding things that would frighten them, hurt them, so providing them that safe place, providing them a place where they can go if they feel like they're anxious or stressed out.
Knowing that they can come back to you at any point and things are going to be okay. Soothe, similar to that. Being able to help them kind of cope with their emotions and their situations. Children's brains actually get regulated through their parents, right? So we understand that children need their parents to help regulate their emotions. So being able to connect with a child in that way and help them regulate their emotions. And then being secure, so helping them develop an internalized sense of well-being.
And one of the things to keep in mind is what, in clinical terms, you just call congruence. It's being able to be present not only saying something, but it's actually having your nonverbals matching what you're saying. So if your kid comes to you and they scratched their knee and they say that they have a boo-boo and you say, "Oh, you're okay." What is that saying? But then if you're saying, "Oh, you're okay," and you're giving them open arms to come and hug you, it's a very different thing.
So being congruent in your actions, having your nonverbals matching the things that you're saying. So this is the circle of security. This is an attachment...this is a way to provide a picturegram to provide a how do you provide a secure base. So what this means is that the child needs to go out and they need to explore and they need to develop mastery and competence. And they need the parent to watch them and be part of that, but when they start to feel anxious or stressed out or they feel like this is too much or they start to get overstimulated or dysregulated, what do they do then?
They need to know that they can come back to you and you can provide that consistent, secure base over time. And providing that secure base and providing that consistency is going to build resilience in the children, in your child. So being safe, being consistent helps foster resilience long-term. So now let's talk about mirror neurons. So mirror neurons are these specialized brain cells that actually shift and change in response to who we're observing.
So let's just say you're sitting with...you're a counselor and you're sitting in therapy and your client starts to cry. It's my ability to sense that and my ability to shift and change my own perception and my own feelings to kind of understand what's going on for that specific individual. Well how do you think that's important for babies? So, one of the things that Dr. Levitt was talking about was serve and return. It's all about those exchanges.
So when a child is reaching out and they get met with a happy face or a calm face, what does that do? It helps them regulate. It helps them be calm and be consistent. And that gets hard-wired into their brains. But what happens when a child reaches out and their mirror neurons are seeing a parent who's chaotic and disorganized and unresponsive? They get confused and then those types of patterns become hard-wired in their brains.
So like I said, with the slide before, the nonverbals are really key and really critical because children see everything and they observe everything. So here's a picture of someone, looks like a man, yelling at a little girl. And what happens over time when you consistently have engagements or you have interactions with a caregiver that's unresponsive or chaotic or disorganized? Well that's what we call interpersonal or attachment trauma.
So a lot of times you see this in moms who have unresolved trauma themselves, right? The child wants to go and they have this inherent need to go and want to cling to that person because that's their caregiver. They want comfort. But at the same time, that same person is the person who's providing those unhealthy, ill-adaptive interactions. So that child clings to their source of trauma. So what do you think that does to their brain architecture? It really messes it up.
So the safe haven for these children is filled with fear and emotional dysregulation, and that creates a new generation of victims. So what we're seeing in the literature is these children that have attachment trauma and severe attachment trauma. They don't exhibit the same types of symptoms that someone who has PTSD would. These children have more of a complex trauma, okay? And there's this movement now to include what's called Development Trauma Disorder into the next version of the DSM, because what we're able to see is that children, the majority of children that are actually getting treated for trauma are not presenting with your typical kind of PTSD-like symptoms.
They're actually presenting with things like ODD and conduct disorder and ADHD and anxiety disorder. And all of these things are on the rise. All of these diagnoses are on the rise. And what you're able to see is these diagnoses are trauma-based. They're trauma-based diagnoses. So it makes it hard for clinicians, too, because they're seemingly unrelated disorders, but actually they're coming from trauma. These are trauma-based disorders.
So let's think about the brain and let's think about how it develops. Well the first part of the brain that develops is the right hemisphere. That's that sensory-based side of your brain. So all of these interactions that happen in the earliest years impact that right side of the brain function. So one of the things that you see in young children who have impairments is in the right side of their brain, is their inability to relate and their inability to regulate their own emotions. So these earliest interactions that you have in the first 18 months of life, they store the internal working model for attachment relationships and affect regulation.
So the interactions that you have in those first 18 months of life are very much right brain mediated. And it's the right hemisphere that requires that emotional stimulation in order to develop properly. So how do we treat ACEs? So knowing all of what we know about early childhood trauma and how that works in the brain and how we need to be able to support and foster healthy attachments, it's the answer's pretty simple. We need to treat ACEs through relationships.
We need to treat ACEs through relationships that foster healthy attachments that promote resilience and healing. And it's the attachment piece that really helps with not only self-regulation and helps with that right hemisphere and brain development, but it also helps in terms of being able to have trusting relationships yourself and develop trust and security. So one of the things that in clinical terms what you want to do is look at the system.
So this is a picture here of my hero, Murray Bowen. And Murray Bowen, actually I'd only learned this fairly recently, was a distinguished professor at UT. But he actually started the Georgetown Center for the Study of the Family and was a professor of psychiatry at Georgetown University. And during my doctoral studies, I actually studied and trained at the Bowen Center. And Murray Bowen is the founder of family systems therapy.
He's the person who trained during the height of psychoanalysis, who said, "Wait, let me take a step back here because what I'll say is that we don't operate in a vacuum. We don't exist in a vacuum. And in order to understand mental disorders we have to understand the system in which we're functioning, that our relationships impact the development of disorders. That we have these social relationships that really play into how our symptoms appear, what they look like, and how they change over time."
So one of the things, when you're thinking about working to have an understanding of your own attachment history, is thinking back. What were the relationships like in my own family? What were my parents like? What were their relationships like? He talks about going back intergenerationally and looking at different patterns, because these patterns get replicated time and time and time again and get transmitted to future generations.
So a parent needs to be able to reflect upon their own childhood, recognize the patterns and pains in their history, and be able to separate their own past experiences from those of their children. So they don't need to be able to do it as necessary to meet their own needs. They need to be able to meet their child's needs. And they shouldn't be responding because of their own unprocessed wounds.
So one of the things that when you think about intergenerational transmission of ACEs, you need to understand the impact that attachments have on an individual, because you typically will attach in the way that you were taught to attach or the relationships and the exchanges that you had as a child. However, the good thing is that in exploring these things and having that understanding, you can have this earned autonomy or an earned secure attachment.
And this is something in therapy. It's about building a coherent narrative, building a story, having and understanding of those dysfunctional patterns, but not only having that understanding. Once you have that understanding you can choose not to continue to perpetuate these patterns into the future. So last week I came here and I listened to Dr. Stuart talk about how we need to look at children differently, for the children who suffer from severe complex trauma, and instead of saying to the child, "What's wrong with you?" say, "What's happened to you?"
So here's what I want to say about this, with Murray Bowen and with the understanding that systems influence the development of disorders and get perpetuated over time. I want you to say, "What's wrong with the system?" not "What's wrong with my child?" One of the things that you see all the time in therapy is people bringing their child in and saying, "My kid was diagnosed with ODD. You need to fix them." "My kid was diagnosed with ADHD and they're having problems. You need to fix them."
It's not about that. Those behaviors and those symptoms are a response to the ineffective system. So thinking about it differently is hard because it reassigns blame. It's not just your child that's the problem. It's the system and it's the inefficiencies of that system. But the beauty in that is the only way you can change your system and change the system is by doing things differently yourself.
So thinking about and recontextualizing is so powerful, because it shapes the way that you react, that you interact with your child, but then that gets continued on and perpetuated into future generations. So you can change the system. So the next thing parents need to keep in mind is attunement. So Dan Siegel talks about how attunement is the fundamental characteristic in a secure attachment.
So what does attunement actually look like? It means that you're in the moment. He uses the analogy of a fork and the vibration, that it's like a tuning fork that you're able to feel and sense and be present and be aware and be in the moment with your child. So what attuned communication does is it enables the child to develop regulator circuits in the brain and it gives them a sense of resilience. So attuned communication fosters resilience.
And now let's talk about mindfulness because mindfulness really is the key to attunement. So mindfulness has gotten a lot of attention and a lot of publicity within the last decade, really spearheaded by the work by Jon Kabot-Zinn and mindfulness-based stress reduction. Mindfulness can be a scary concept as well because people don't really know what it means. So mindfulness, it means being aware. It means being in the present moment in a non-judgmental way.
And when Kabot-Zinn explains it or talks people through it, it's about following your breath. It's about being in the moment and being able to follow your breath and any time any thought, image, worry, anxiety, or fear, or thought for the future comes into your mind, recognizing it but then letting it go and refocusing back on the breath. That can be really hard and that can be really difficult, so one of the things in therapy that's very effective is grounding techniques.
Similar types of results in that you're trying to get that person right back into that present moment. So grounding techniques typically focus on your five senses and it's five, four, three, two, one. So five things that you see, four things that you feel, three things that you smell, and basically getting that person to be centered, to be grounded in that moment. And why is mindfulness important in parenting?
Because what it does is it gets you in that moment, it gets you able to connect in that way. So when you're attuned and when you're mindful, you're able to see those child's needs. You're able to see their rhythms of engagement and withdrawal. So when you're mindful and when you're attuned, you are being consistent. You are being calm. And over time your child's emotions and behaviors will mirror what you're showing them.
So back to Dan Siegel again. He writes a lot and this is "The Whole Brain Child" as well. He writes a lot about integration and how integration and brain integration really fosters self-regulation. So having the ability to recognize your child's arousal state and keeping that at a manageable level. So if a child is in a state of panic or what he talks about is the lower brain stem tantrum. He talks about the different parts of the brain and the lower brain is the reptilian brain, and that's the part of the brain that's responsible for fight or flight and all of those kinds of intense feelings and urges and emotions.
And then your upper brain is that thinking part of the brain, or as he calls it, the mammal part of the brain. So if your child is in this lower part of the brain meltdown, being able to calm them, being able to soothe that most primitive part of the brain. So a lot of attachment-focused work is about soothing experiences, about laughing experiences, about calming them down and helping them to stop from dysregulating.
And then once a child has developed a secure attachment, he talks about different ways in which, or different strategies in which you can work with a child to integrate both the right hemisphere of the brain and the left hemisphere of the brain. So one of the things he talks about is naming it to tame it. So if a child has a complete meltdown because they're really upset about they lost a basketball game or something like that, it's naming that emotion, but it's focusing on connecting with that right part of the brain, that sensory-based part of the brain.
You're connecting first. Then you're redirecting, so that means that you're bringing that left side in, that left hemisphere in that's going to explain and it's going to process all of those things. So it's about integrating those two parts of the brain in an effective way. But each time self-regulation is achieved, your child grows new neurons, which enrich the web of neurological connections between emotional and logical regions of the brain.
So keeping in mind that all of these seemingly simple interactions are really helping to integrate a child's brain. And now I want to talk about attachment-based therapies. A lot of the things I talked about before were things that parents can do. These are more of the structured type therapies that children who are coming in with histories of trauma are going to be doing. And the purpose is actually the child needs to experience what they missed when they were younger.
They need to be calm, and they need to be in an environment, and they need to learn what it's like to be in a nurturing environment. So the purpose of these types of interventions really are to reduce the level of stress and arousal in a child. And it also goes back to the developmental period where a child's attachment actually got damaged. So a lot of these things are going to be focused on that period of time where those attachments got broken.
So changing attachment relationships and working in that hemisphere is very multi-sensory. And the reason being is because it's going to focus and it's going to engage that right side of the brain. So one of the examples or one of the methodologies that's very common is Theraplay. And there's a lot of physical touch in Theraplay. And why is that? It's to replicate what normal parents do with their young children, because that sensory part of the brain, that right side of the brain is the first to come online.
So that close bodily contact activates the release of common hormones and opioids and oxytocin and all of these things that actually help calm and regulate the brain. So the more touch a child gets, and this in Theraplay really needs to be introduced gradually because when you remember, when you're working with children who have a trauma history they can go in a lot of different ways. They can be overstimulated and dysregulated. They can be completely avoidant and withdrawn.
So all of these things need to be structured in a very specific way because you need to be mindful of how that child responds to stress and how their bodies have learned to respond to the stressful conditions in which they've lived and been brought up. So the goal is to increase capacity to tolerate their situations without...or to tolerate excitement or to tolerate touch without dysregulating. So attunement and regulation are the key components in attachment-based work.
So there are a lot of different interventions. I had come here a couple months ago and done a demonstration for some. So for a child that's having problems with touch, giving them and assigning them, first very gradually introducing touch with a parent and a caregiver. And all of these interactions, you're going to be working with a caregiver and you're going to be introducing things gradually so that they become comfortable and they become accustomed.
So they have things like having a cotton ball and taking a cotton ball and having them just kind of draw little circles. And having the child be able to respond to touch, so lotioning up a boo-boo, and then as they grow more and more comfortable doing things that involve gaining mastery. And then children who have problems with self-regulation, teaching them games like Red Light/Green Light and Mother May I and things in which they're able to kind of develop that capacity to self-regulate.
So all of these types of interventions are very highly structured based on the needs of the child and how they respond to their caregivers and their needs. So this last slide really is me just kind of echoing the words of Nadine Burke Harris. She's a physician out in California who really talks about that ACEs are not just a message. They're a movement. And the awareness involves so many people and passing on that message, and being part of that movement, and being able to unite, and being able to...one of the things that would be the greatest would be to put Memphis on the map for being the place in the country, being the leader to fight ACEs.
So one of the things, from my department and my colleagues, I speak for myself and my colleagues. Those of you who work in social services or in research across the city, reach out because we want to partner, we want to make a difference, and we want to help the community, we want to help fight ACEs. Thank you.
Dr. Dan Goldowitz: Okay, great. Thanks very much, Eraina. We have time for questions so let me kick things off and then I'll turn it over to Rob, but this is the question he was going to ask. So we heard from Pat about individual differences, right, and how that plays out. But we also know about kids who are like dandelions you can tromp and stomp and they still grow and flower, or orchids that are much more delicate. How does the orchid or dandelion type child play out in your intervention scheme?
Dr. Eraina Schauss: Well, I guess it depends whether they're showing up for therapy or not. So if they're coming in for therapy, obviously there's going to be something going on. So it all just depends on how physiologically or how emotionally they were able to adapt. And I think part of the piece could be the epigenetics, the genetics that they were given at the time that they came out into this world. So I think a lot of it depends on it's the epigenetics but it's also the relationships and the attachments that really foster and make...we're able to see those differences.
Audience: At UTHSC we're very interested in putting together a study of genetics, epigenetics, of ACEs, so coming back to your last slide. So how many patients, subjects do you have access to at the U of M? How many people come through the clinic or do you have a clinic?
Dr. Eraina Schauss: So to answer the question, when I talk clinically, it's based on the work that I'm doing with the Universal Parenting Places in ACEs. However, at University of Memphis we are hopefully in the process of building out a clinic, currently within the next year or so. So that's something in the future that hopefully the horizon will hold for us.
Audience: So you spoke a little bit about interventions to use with children with adverse childhood experiences. Are there interventions for adults and is it ever too late to work against those?
Dr. Eraina Schauss: I don't believe it's ever too late. I think one of the things to take away from my talk that's probably the most significant is the importance on building that coherent narrative because what we're able to see with parents who have a severe attachment trauma themselves, in understanding that story and understanding those relational dynamics and how they play out over time, just having that awareness gives that person so much power because they can choose to replicate those patterns or they can choose to stop them.
And some of the best parents are actually those parents who have that recognition and don't choose the same path that they were given. So absolutely, there's always hope.
Dr. Dan Goldowitz: More questions? Yeah.
Audience: So did I understand correctly that you say ADHD and ODD are early trauma experiences?
Dr. Eraina Schauss: Yes. So they're not the sole reason, but what we're able to see is that children with a trauma past have higher rates of those disorders. And they're coming in and they have these behaviors that are related to the environment in which they grew up or the relationships in which they had, so absolutely.
Audience: And just to follow up. So are the attachment experiences or behaviors, a lack of behaviors, recognized enough so that you can...like for example, autism for example. You said the earlier development, you can see some behavior symptoms that points to autism. Are there such things for attachment?
Dr. Eraina Schauss: Absolutely. You can see and you can notice. Some of the earliest studies that have been done are like the strain situation and things of that nature where a child is...the caregiver leaves the room and the parent leaves for a minute or so. And what they're able to see is when the parent reenters, so when the parent leaves the child will melt down. And it depends on the way in which that parent reenters the room.
So a child that has a disorganized attachment, even though the source of their comfort is the parent, that parent has been so inconsistent in their caregiving that the child doesn't calm down instinctually. The child doesn't calm down because of that relationship. They remain dysregulated. They cry. One of the types of interactions patterns is that child who's crying, the parent comes in and the child just completely shuts down. They become completely avoidant, completely withdrawn.
So just in these very early interactions with 18-month olds, you can see these patterns between parents and caregivers. And you're able to see, if you were to follow those children over time, the development of all of these emotional and behavioral disorders.