so the title of the talk today is the science of risk and
TRANSCRIPT
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So the title of the talk today is the science of risk and
resilience impatience for best practice in child welfare.
I'm a professor of Psychiatry at Johns Hopkins and also director
of research at the Center for Child and Family traumatic
stress at Kennedy Krieger, which is a Hopkins affiliated
hospital. I'm so what my goal is to do to talk a little bit
about what we know about the science of adversity Translating
that science into actual practice.
And then I'm going to actually give you some different clinical
vignettes that you can break into groups and scream isn't
100% conducive towards breaking into groups, but to break
into groups and then to think about given what we know about
the science of adversity factors that promote resilience.
How can we potentially think differently about helped, you
know how to promote positive outcomes for the different children
and communities beignets.
Key Concepts that are going to be recurring in this presentation
is the idea of neuronal plasticity people used to think about
brain development is being fixed, but we know that experience
can change the way the brain functions and also neuronal
genomic plasticity.
Gene effects are also not fixed experience affects how genes
function and you know the opportunities for Recovery as well
as for Psychopathology.
So the science of adversity I'm assuming everybody in this
room is familiar with the ace study adverse childhood experiences.
We know experience of child maltreatment are associated with
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increased risk of all sorts of health risk behaviors, like
overeating smoking drinking but above and beyond the effects
of these health risk behaviors adverse childhood experiences
things like child abuse and neglect are associated with all
sorts of negative Health outcomes, including ischemic heart
disease stroke respiratory problems diabetes and even cancer.
And this has been highly replicated over the past 20 years
and more recently.
We're starting to understand that epigenetic mechanisms.
May she was good because question how do these early experiences
lead to that broad range of different Health outcomes and
epigenetic mechanisms are essentially chemical modifications
to the gene.
So as I said genetic effects are not fixed and what we're
learning is that variation and experience can lead to editions
of things.
Methyl groups we can trace back to when we took chemistry
whenever that last was carbon and three hydrogen's that changed
the three-dimensional shape of the DNA and the likelihood
that a given Gene is expressed or created or not creating
and that child abuse has been found to be associated with
these methylation these carbon hydrogen changes in genes
involved in stress raft reactivity brain development and
also the broad range of different health problems that we
just talked about ischemic heart disease.
These diabetes respiratory problems and even changes in genes
involved in cancer.
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So the first study that we did this sort of highlighted up
there. We didn't have health outcomes.
We just saw changes in genes associated with all the different
types of health problems that have been associated with adverse
childhood experiences.
I'll tell you more about sort of the next steps.
But before I just sort of want to give more of an introduction
about what we know about epigenetics and stress and a lot
of this comes initially from work that was done in animals
that people are familiar with Mike matheny's Plastics.
Do a little bit of an introduction to this and I appreciate
that. This is a very busy slide.
But what I want you to look at is all these different dots
and arrows highlight all the different parts of the brain
that are involved in the stress response.
The brain responds to stress in a very orchestrated and highly
complex matter.
But if you notice all the little red dots are areas of the
brain that are involved in Emotion processing all the little
green dots are parts of the brain.
Pain involved in reward which is relevant for both depression
and things like substance use disorders and all the blue
dots are things involved in executive functions things like
impulse control.
So when you think about all the different parts of the brain
that are involved in the stress response, it's not surprising
that individuals with a history of child abuse and neglect
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are at risk for Psychopathology related to all those different
sorts of brain circuits that are involved in the stress response.
The good news is we talk today.
We're not going to focus on the entire brain.
We're going to focus on the hypothalamic pituitary adrenal
stress axis where the stress response begins.
alright, so looking at you a little bit more limited way
the stress response with begins with the release of crh,
corticotropin-releasing hormone from the hypothalamus that
leads to the release of ACTH from the pituitary and glucocorticoids,
which is cortisol from the adrenal an important sort of take
home message from this picture is you'll see glucocorticoids
of cortisol feedback to shut off the stress response and
they feed back with two important places the hypothalamus
and the hip And hippocampus is going to be a structure to
keep in mind because it's absolutely key for putting the
brakes on the stress response.
It's all right.
So a lot of how we first learned that experience and a faint
affect gene expression stress reactivity and the associated
with a whole range of negative outcomes associated with early
life stress comes from the very seminal studies of my community
and colleagues and they had a rat or Mouse model of maternal
neglect. So needless to say it is a lot easier to determine
in a rodent.
What is neglectful parenting versus what is neglectful parenting
in humans?
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Delightful parenting in you and rodents is an absence of
licking and grooming.
Okay, so that they saw that there was natural variant ation
variation in parenting in rodents.
So that some were just optimal non-stop living in groomers
and that led to you know, what you see over here is you know,
these high licking and grooming Optimum moms had offspring
that we're really stressed out not a lot of stress reactivity.
Not much for your behavior, but the Who's on the other end
of the Continuum that what they called neglectful rap mom's
very low and not a lot of licking and grooming in novel situation
their offspring showed really high stress reactivity and
lots of changes in multiple biological systems.
And this was highly replicated and also continued on until
adulthood. So this has been highly replicated and very consistent
where they shown variation maternal behavior is associated
with consistent behavioral differences stress reactivity
propensity for anxiety type behaviors propensity for depression
like behaviors and what might be needy and his colleagues
were able to find out is that variation in maternal care
prototypes long-term changes in that glucocorticoid receptor
gene expression in the hippocampus.
So remember the glucocorticoid receptor It's the fupa corticoids.
It's called glucocorticoids in rodents, but it's just the
equivalent of cortisol a stress hormone.
And remember the hippocampus is really key for putting the
brakes on the stress response.
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And if you see in The Offspring of the high licking and grooming
animal all these little dark blond dot dots those are glucocorticoid
receptors right there ready to put the brakes on the stress
response when an animal experiences any type of stress response
versus in the low looking in grooming animals, you see there
really are not very many of those receptors.
And so essentially if an animal gets stressed if they have
this optimal period parenting they got the low stress reactivity
High glucocorticoid receptors.
They basically can shut off the stress response versus the
other animals do not have that little receptor to sort of
shut it down and it just continues And so then the next question
is how do you know it's really the variation in maternal
care not due to individual differences in the parents or
potentially to something prenatally and what you can do in
rodents that we wouldn't readily ever do in children is these
beautiful cross-fostering studies?
So essentially what they've done is they took the offspring
that below licking and grooming need like four moms and at
Birth put them with these optimal highly can be from the
animals and what you see Is that the ones who may have been
born to these non optimal mom's when they're given the optimal
parenting they essentially showed low stress reactivity low
anxiety and vice versa.
You take The Offspring of that high licking and grooming
animal but you re some women is left for Mom and then behaviorally
and ideologically they look like offspring of the neglected.
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So it really was the very first studies to show variation
in in maternal care.
Early Childhood learning can affect gene expression in key
areas that affect stress reactivity and risk for various
behavioral types of problems.
You talk just a little bit about these chemical modifications
that are affected by environment change the three-dimensional
shape of the DNA.
And so what you see here.
When it's methylated like we talked about it's really highly
coiled and then you're not going to get that glucocorticoid
receptor that you need to help control the stress response
versus in these offsprings the highwomen commune booming
animals where it is, really not all tightly coiled like that
and sort of sense this seminal work.
We found out that early adversity leads to changes in a broad
range within our study comparing children with a history
of severe maltreatment necessitating out-of-home placement.
Demographically matched children with no history of that
type of adversity at all based on kind of multiple things
the two groups of there's something called an aluminum Beach
where you can look at 450 thousand of these epigenetic types
of markers.
And so if you're looking at group differences you have to
control for that.
So it's got to be 10 to the minus 7 point and we had more
than 2600 markers that were different between are maltreated
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and our comparison and when we Great.
There's this great program to input it in a computer and
figure out in one of these genes mean they were changes in
genes involved in those different health problems that have
been associated with adverse childhood experiences jeans
relevant for psychiatric disorders substance, use disorders
cardiovascular disease diabetes and even cancer.
It's so a project that we are currently doing which is how
I got to meet your secretary and are working collaboratively
with DCF is looking at Social adversity epigenetic epidemic
and we are recruiting through Hopkins All Children's moms
who are at high risk getting information about their own
adverse childhood experiences the stress of children over
time and looking at various different epigenetic markers,
which we have identified as well.
So that is just a quick bow.
And now how do we translate what we're starting to learn
about the science of adversity into best practice?
And the important take home message is while these epigenetic
and other biological changes associated with early adversity
are often long lasting.
They are not necessarily permanent.
And I don't know how many of you were exposed to this in
your undergraduate education, but I remember learning about
these experiments.
Do you remember the cats who had their eyes so that they
didn't get any visual stimulation and it led to long-term
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changes. These little boxes are ocular dominance columns.
So long-term changes in the development of the visual cortex
in the brain and then an absence of visual Acuity into adulthood
and a lot of people used to translate this into.
Well what We know about kids with adversity early adversity
leads to long-term permanent changes in the brain and you
can't fix it.
Okay, but what we've been learning says those seminal studies
is that the negative effects of you know, not having Vision
exposure because the experience-dependent experience affects
brain development.
That's a really key thing.
We've learned it's not all pre determined based on genetics,
but those Those ocular dominance changes associated with
you know, an absence of visual experience early on are associated
with epigenetic mechanisms those chemical modifications.
We've talked about and normal visual Acuity and restoration
of those ocular dominance columns can be restored.
I have no idea what someone thought to try fluoxetine Prozac
but believe it or not.
You can restore visual Acuity as well as this ocular dominance
columns. And the one on the left I think is also really important
to think about it.
It's in Richmond.
During the Adolescent period so again the idea of a critical
period makes it sound like a done a no, I prefer to use the
word sensitive periods.
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There's without a doubt periods of brain development that
children are more sensitive to input from the environment.
But we continue to have neuroplasticity into adulthood and
Adolescence is also another very highly sensitive period
so in these experiments they had the animals have enrichment
in there.
Paige has all sorts of nasty things and it led to the visual
Acuity rest for the restoration as well as the normalization
of the brain development.
So important take-home message just because you miss one
sensitive window of development doesn't mean there's not
an opportunity to promote recovery in other periods.
All right, so promoting resilience and maltreated children
and tipping the scale and paper positive outcomes.
I really do focus on three primary things one is attachment.
To enrichment and three is child and birth parent services.
So I do have to warn you I often do go back and forth between
talking about rodents and talking about you evidence.
And so always tell me when I do that it sometimes you can
feel a little apologize if it feels it's a friend.
That's the way my brain works.
All right.
So this is work that was done by Paul Potts and colleagues
who had a different model of adverse early experience that
they looked at in in mice and rats and so early separation.
And like MiMi study, they found animals exposed to early
deprivation and separation from the caregiver had heightened
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stress reactivity.
But one of the things that Paul Potts, you noticed that in
addition to kind of the separation the moms parenting went
out the window her pup.
And so he asked the question.
Well, is it really just the early adversity or is it the
lack of really optimal good parenting wants the child.
Child is returned where the rat money is returned to his
mom. And so he did an experiment where he used ideal foster
moms who provide that non stop licking and grooming and so
you had animals like either had the ideal rearing they were
deprived or they were deprived but then given these optimal
foster parents and what you can see is For those animals
that had early deprivation but then optimal subsequent here
getting there was a total restoration of the HP axis of stress
response. It was only those animals that had early deprivation
and no follow-up optimal kind of caregiving to help with
that restoration.
And how many of you are familiar with very Josie's and hatching
biobehavioral catch up model of intervention.
So we know infants who enter the child welfare system often
have Disturbed attachment relationships.
And even when you put them with a new foster home, they continue
to have Disturbed attachment relationships when they're distressed.
They don't know what your Giver for Comfort when they get
picked up then lean back like this.
So Mary go see you developed an intervention to really try
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to promote.
The meditation among children with a history of early child
maltreatment and in the foster care system and sure enough
what she found with the Improvement of the attachment that
there was a normalization of the cortisol response to stress
that these changes and improvements and stress reactivity
are maintained three years out as well as there's less, you
know, internalizing and externalizing behaviors.
So again Improvement in the attachment relationship is really
key towards promoting resilience.
It's and restoring those biological systems that add risk
to Psychopathology.
This is a study that was looking at cortical thickness, you
know beyond kind of the extremes of child maltreatment.
Just the toxicity associated with poverty is associated with
changes in children's brain development and sure enough what
they found well whether or not there really are negative
effects associated with severe poverty is modified by positive
parenting and for those who are living even in the most extreme.
Circumstances with positive parenting you have greater cortical
thickness in the areas involved in Emotion regulation executive
function the amygdala key things that lead to the Psychopathology
so that preventing that so again adversity toxic stress.
Nothing is a guaranteed that outcome.
I have worked with an E Casey Foundation these Law Center
and multiple colleagues around how does this translate and
the use of family-based care versus institutional care and
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there has been a consensus for a long time the UN convention
on the rights of the child that young children have a right
to be with the family, but that teams adolescence through
pain group home for a pain institutions and really the take-home
message from the regime of the make sure that we published
in consensus paper is that Children and adolescents need
the right to grow up in a family with at least one committed
stable loving caregiver and that group CARE should never
be favored over Family Care, even if it's family like and
that it's only should be used when it's used for therapeutic
services long short term not the idea that children are going
to grow up and before coming down to Baltimore.
I was in Connecticut for 18 years and when we first started
Work we had about four to five hundred children and out-of-state
residential treatment facilities that were essentially just
you know separated from any possible Family Ties and living
there until they were emancipated and on their own so that
there's really been a remarkable change that number is down
to less than 50.
We used to have 20% of her birth to five year olds going
into these congregate care settings now, it's never more
than a handful and education medical necessity and the United
Nations. Is actually also taken up our position.
So in this disabilities rights International is highlighting
that there's now been an acceptance that you know, it's not
only not optimal for young children.
It is an optimal for older youth as well.
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I don't know how many of you are familiar with the Bucharest.
So the most definitive study showing the negative impact
of institutional care is the Bucharest study which was done
in Romania.
We're all children if they didn't have caregivers were raised
and institutions and Charlie Xena and others said let us
do a randomized control trial because you know, whenever
you show institutional outcomes are bad is it just the kids
were in the institutions versus, you know, something about
institutions and so they were able to do a randomized.
And kids who stayed in the institutions versus those who
were given optimal foster care and they found you know, long-term
changes and improvements and stress reactivity lower rates.
Well, if you stayed in the institution you had higher rates
of psychiatric disorder higher rates of cognitive deficits
and the less time that was spent in institutional care the
greater the development gains.
So that was really a new one and only study that's been done
but as shown, you know in a randomized Troll file.
This is a study which was a propensity match sample and the
data also suggests a group CARE increases risk for delinquency.
And this was a very large study of Youth involved in the
child welfare system where they completely matched based
on age of first placement race gender total number of placements
placements related to going AWOL changes related to child
behavior problem of child abuse all these things the two
groups were matched on and if you look at the kids who were
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in foster care versus group CARE In the group CARE there
was a 2.5 increased risk of delinquency, whether it's contagion
or it's also you know, the point is rotating staff was no
substitute for a parent you wake up in the middle of a nightmare
nightmare who's going to be on so there is no substitute.
And what we also know from research is that those living
in residential care at higher risk of physical abuse and
compared to youth in foster care.
It's about a two-fold increase rate or compared to the community.
So again, you know, even with best intentions, it's hard
to keep children safe in those environments.
I was fortunate as graduate student at Yale to work without
solve it with some of you may or may not know it was one
of the authors of the books about Beyond before the best
interest of the child and one of the things he said to me
which always stayed with me which is all the best professionals
does not make one good parent in the bottom line.
Is that children need 24/7 lifetime parents threat recognized
All right attachment is important and now we'll talk about
enrichment. All right, I did warn you I'm going to flip back
and forth between mice and humans.
So here you see once again our animals with it low licking
and grooming and as we saw before the animals with high licking
and grooming have lots of these glucocorticoid receptors
those with low licking and grooming.
They don't have these glucocorticoid receptors.
Really key for controlling the stress response risk for Psychopathology.
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So in this experiment they provided enrichment again in adolescence
is outside that initial sensitive window and what you can
see is the animals exposed to low licking and grooming Don
optimal early parenting that then had the enrichment experiences
develop more glucocorticoid receptors decrease stress reactivity.
And so when we think about what sort of things in children
might change brain development my colleague Jim Hood Zach
was interested in what's the effects of musical training?
So you would expect someone who plays in the violin would
have maybe developed cortical brain regions where they use
their fingers, but what he found is that youth also have
greater cortical thickness in the areas that are involved
in emotion and impulse regulation not just No coordination
and things like that and so he is actually so this was you
know cross-sectional and he's actually doing the study with
kids with ADHD where the intervention is teaching them that
I live.
And is that going to be associated with changes in brain
regions that are key for emotional and impulsive regulation
and I think it's really changed the way you think used to
think. The only way to change the brain is with drugs ECT.
But what we're learning is various types of Oh therapy new
experiences mindfulness interventions changes functional
connectivity and key areas that are involved in Emotion inhibitory
control executive function top-down control.
So again, we don't need we don't always need drugs.
We don't always meet things like ECT things like teaching
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mindfulness and I'll show you in just a little bit also Psychotherapy.
So this was a study that was done by Ron Kessler and colleagues
doing longitudinal follow-up of kids who?
Problem Casey foster care system and for those of you who
are familiar with a tasty is really the equivalent of the
optimal cath lab version of foster care kids get music lessons.
It's beyond sports teams.
They also provide them with therapy counseling tutoring other
such things and what you see compared to kids who were in
just State foster care.
They as adults have much lower rates of major depression
lower rates of anxiety and substance use disorders, too.
So high on the anxiety but again and it probably works in
written language.
So these berries enrichment experiences probably do help
change the way the brain is connected and functions, but
it also gives the opportunity for youth have other positive
adults in their life and also develop self-esteem.
So a lot of times when we're thinking about how can I help
tip the scale for this kid to be thinking about what are
some of his strengths Ritter ways in which I can encourage
him to have that positive sense of self-identity.
There's a program in Baltimore called red which works with
some of the highest need kids in the Baltimore area.
So these are they using so I should get this statistic right
because I've been in Baltimore more than two years, but I
think our graduation rate is not even that means there's
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that they disclose their 65% and so they brought the rolling
kids who are in the bottom 25th at their class.
So that's already of cohort.
That's a high risk.
They matched.
Team with a cohort of five volunteers customize the support
for each child and actually provide intervention for 10 years.
It's not a quick fix, but it's saying how do I support this
child and family because they're at risk for all the bad
things one can imagine and what they found is that 92% of
these youth who are at the bottom quarter of graduated high
school 92% have been accepted into college and 80% complete.
Added a former to year.
So again that sense that up, you know, they're laid out of
lessons. They're failing throwing up your hands, you know,
and this is really a combination of both attachment and enrichment
really being able to turn the tides around.
College tuition from the sample was of the children at Brad.
I'm not exactly sure but they have they worked with a hundreds
of kids Focus Point.
Yeah, so it's been going on for a while and you know works
with volunteers and but you know, but again, it's you know,
it takes a village so in Florida you have tuition waiver
here, but again the opportunities that that can provide to
Change the trajectory of children.
All right child of birth parent services.
Most of you I'm assuming are familiar with trauma-focused
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cognitive behavior therapy.
It is the treatment for children with PTSD other trauma related
symptoms that has the highest evidence-based and it's known
for its practice component P psychoeducation, whether the
effects of trauma teaching relaxation skills cognitive coping
a trauma narrative is a part of the intervention and Vivo
Mastery of reminders and enhancement of safety.
and in one study that is looking at TF C BT with children
in foster care that boy only was associated with greater
improvements and PTSD emotional and behavioral problems and
treatment as usual the Tau the you think that TFC Beauty
were half as likely to experience the placement disruption
and one type is likely to run away and if you think about
it the importance of involving foster parent or relative
caregivers in the treatment so that they can understand what
are the triggers that The child off to decrease the likelihood
of those behaviors that can sometimes lead to placement disruption.
Txt BT is also very effective in terms of sexual acting out
behavior. And one of the first studies that was done by Judy
Conan colleagues.
Basically, none of the children the TF CBT group had to be
moved or how to change in placement due to sexual acting
out behaviors versus a good number of the youth in the treatment
as usual and that it is an effective way to Target these
behaviors in our children.
We've talked a little bit about you know, the impact of trauma
on the brain.
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One of the most highly recommend finding is this increased
amygdala, keep are involved in Emotion processing associated
with anxiety symptoms and history of trauma and this is a
study by sister and colleagues where they look to see brain
Imaging before and after T of CBT those youth who favorite
who responded favorably had increased connectivity between
Ranges that are involved in Emotion processing in the amygdala
and again, so as I said, you don't always need drugs to change
how the brain is wired.
And that teaching people skills.
They can use when they feel anxious, you know building those
supports in those safety and change the way the brain is
wired. I'm just going to go over a couple of other types
of interventions because as you'll see I am a key advocate
of really minimizing the use of congregate care settings
and one of the types of behaviors that often get kids in
congregate care settings is that they're doing self-injurious
behaviors or Barry substance use dialectical behavior therapy
if people are familiar with is an intervention of very effective
at targeting these things can be done on an outpatient basis
provides a combination of skill base.
I'm learning around emotion regulation distress tolerance
mindfulness and the like a very important interventions part
of the Continuum of Care for kids with a history of trauma
in terms of substance.
Use that's another thing that can often get kids sent away.
But we really do have several, you know outpatient or intensive
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outpatient programs that can be you'd where children can
safely get substance abuse treatment without having to be
sent to any residential facility of motivational interviewing
termites. Difference there's there's fill my system interventions
dialectical behavior.
Therapy also has a substance to use variation some multiple
things that can be used as well.
Multi-systemic therapy.
So again sexual acting out Behavior.
It's been most specifically demonstrated with young children
with TF C BT in terms of being able to diminish those behaviors.
But with older youth multi-systemic therapy was adapted for
teaching. I'm treating juvenile sex offenders and the outcomes
were compared to view through worry.
I've to group CARE instead and they not only had an increase
or a big Improvement in decreasing elimination of the sexual
acting out behaviors that a decrease in Middle Behavior not
just of the youth but if the parents and the siblings and
for those of you who are not familiar with MSD MST really
takes a multi-systemic therapy, and this is what it's called.
Yes.
It takes a whole family approach and it takes a community
approach. So working to help the kid develop positive peer
relations working on strengthening parents ability to manage
youth Behavior dealing with you know, the other systems the
child's involved with whether it's the school or the Juvenile
Justice System intense.
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At home based but really positive outcomes.
Multi-dimensional treatment foster care has often also been
used with a range of different delinquent behaviors with
multi-dimensional treatment foster care also showing out
no better outcomes than food care in terms of rates of recidivism
and then subsequent need for detention here.
So again, there are lots of creative models for some of the
things that we tend to send kids away.
And Therapeutic Foster Care for kids who are medically fragile.
We're lots of times there's incentive kid has a trait you
can't care for in a home.
No, we provide the Right medical supports, of course, the
kid can be cared for him at home.
And we are at Kennedy Krieger way.
I do have a Therapeutic Foster Care Program and it blows
me away.
I did an intake recently on a young child who is living with
a foster mother that had two other medically complex foster
care kids in the house one was wheelchair bound when had
known. I mean, but you know just the care that she was able
to provide.
You know, there's no way 24/7 around-the-clock care in an
institution is going to provide that kind of connection in
that opportunity for growth.
I've talked a lot about the child treatment.
I want to take a few minutes to talk about the importance
as we think about our interventions with youth treating the
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parents and this is a study that was initially done by Maria.
Weisman was an add-on to a very large randomized.
While treating depression in adults is called starting.
and essentially she compared the outcomes of Youth whose
parents depression remitted versus those that didn't and
so if you Look, we just make sure I can see this correctly.
It's too small over there.
Okay.
So on the left are the parents with remission and in light
grey is the rates of Psychopathology before Mom started treatment.
And then in the black is the rates of Psychopathology after
Mom remitted from depression.
No intervention was done with the youth but you can see The
overall rate of Psychopathology went from 35% to 25% by just
helping them up with their depression on the other side the
moms whose depression did not remit.
You see it increases so they start off in the same place,
but you go from 35 to 40% So sometimes our best interventions
is thinking about how can we help the parents?
Because when parents are stronger, it can really help regulate
kids and improve psychology even with no intervention.
Focused on the child substance abuse is also one of those
things are often ends up children substance abuse and child
welfare preaching to the choir, you know, go hand-in-hand
with the best data suggesting 60 to 70 percent of child welfare
girls are dealing with addiction disorders 80 to 90 percent
of the kids who enter out-of-home care parents are dealing
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with addiction disorders and among child welfare cases when
there is substance abuse higher rates of child rape victim
ization longer.
some care High rates of termination of parental rights All
right, so this is old but I think it's really telling so
this goes back to 1998 when the general Accounting Office
wanted to report about tell us what happens to families in
the child welfare system when there's a need for referral
per child welfare, and you see above a hundred parents in
the child welfare system that needed or was recommended that
they get substance abuse treatment 64 percent completed an
intake interview 50% attended one sec.
But only 13% completed treatment and I have to say in my
younger days.
When I started this.
I used to think if there's ever anything that's going to
make a parent, you know, give up their drugs or require you
to recover and losing custody of a child, but I think when
we look at something like this and we see 87 percent of the
parents are falling through the cracks.
Why we have to ask ourselves.
What aren't we doing?
Right and really over the last two decades?
There's been a lot of initiatives to try to improve delivery
of substance abuse treatment to parents involved in the child
welfare system with family tree with reports.
Probably the most widely used really aiming to Target, you
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know, increase access by having, you know assessments writing
the court using recovery coaches to make sure people can
get to their treatment having the frequent judge.
Um drug testing regular Port visits rewards and sanctions
based on use and ultimately their without a doubt improvements.
Although there are limitations and I don't know how many
of you are familiar with the program building stronger families,
which is an adaptation of the multi-systemic therapy model.
So it likewise targets those different levels, but it's home-based
versus being office-based integrates multi-systemic therapy
with reinforcement based therapy, which is an evidence-based
treatment for substance.
Use we're basically you got to clean urine you get a gift
card and they gave initially plan on treating PTSD but as
they were working with moms with in the child welfare system
found that over 8% that criteria for PTSD.
So provided home-based exposure therapy as well 24/7 on call
clinician is a six month intervention.
When are intestine actually in the home safety plans are
developed. So that children can remain home, you know, lots
of times I've worked with kids who basically we left unattended
for days on time.
I doubted whether parents were drug page.
So relaxed it is not automatic losing custody of your child
because if you know, you're going to relapse and you bring
the kids to grandma that's a step in the right direction.
And then if you are committed to continue to work on that
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one country the children potentially can still stay in the
home. So this was the very first open treatment study 87
percent of the parents referred engaged in treatment 93%
of those who started treatment completed treatment.
The majority of cases were retained at home at discharge.
There's another study with a fencing match sample showing
benefit over two years.
The randomized controlled trial date is just about ready
for release, so it's not yet available, but it should be
available shortly and as we compare these two models They
both have intensive case management.
They both have frequent urine testing the integrated parenting
substance. Use and Mental Health Services is very rare for
the families who get family treatment drug court most Community
providers treat substance abuse.
You have to go somewhere else for your mental health.
And if you want parenting you got to go somewhere else which
makes it very difficult for parents to try to make three
different types of intervention with the building stronger
families because it is multi-systemic therapy model deals.
The parenting issues as well as the mental health from the
substance use home-based as we said there's cost saving in
terms of judicial oversight and the randomized control trial
is going to happen across state and I think it's actually
quite powerful from what I've heard from speaking to some
Pious ones and it's not published or released yet, but I
understand the savings were quite significant and again out-of-home
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placement. It's really the minority of cases and I mean one
of the reasons why I think that's so important is you know,
while family treatment drug court has done better than treatment
as usual.
The duration of has decreased from 650 days to 400 Days from
a kid's point of view.
That is an incredibly long period of time and what we also
know is for those families to get the family treatment drug
court. There's very high rates of re-entering to care.
So I think Thinking about alternative models as we deal with
parental substance abuse is key.
So again our take-home message, we want to promote resilience
thinking about interventions and ways to promote positive
long-term stable attachments enrichment opportunities for
children and childhood cancers.
Key Concepts, we talked about or neuronal plasticity genomic
plasticity was various things and take home message is history
of adversity child abuse may not lead to bad outcomes.
There's many things that we can do to tip the scale in favor
of positive outcomes, and it's important to sort of think
outside the box when we think about how to help children
and families the work I've done is and, you know have lots
of collaborators, which I'm very grateful for.
I do join the test tell you though.
I this is a book which I think is a very good teaching tool
Charlie's in the mix all his child psychiatry residents by
it's a narrative nonfiction following the life course of
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two children who were part of our, you know, group home evaluation
or Gene environment interaction studies or Imaging studies
and these youth ended up having 20 placements and their five
years in the system.
I got 1,800 pages of child protective service records.
Did interviews with you young adult children their birth?
Mom various foster parents and places visit all the places
they lived over the years and it's 75% narrative nonfiction
and we start off with a snapshot of the mother's own views
of childhood.
And each chapter is then a launching point for talking about
updates and policy practice and science.
See Mom just as a neglectful drug addict, but as a woman
who got raped five and he was subjected to until she finally
left home at age 16 and that is like a launching point to
talk about comment from systems of care talk about child
welfare and substance use child welfare and domestic violence
all sorts of 50% of the profits been right.
So the attachment biobehavioral Patrick intervention is designed.
So I'm going to give you a little bit more detail since you're
asking It's designed really for infants and toddlers and
it works most effectively when there's an alternative caregiver,
whether it's a relative caregiver a foster care placement.
For those of you who are familiar with child-parent Psychotherapy
when you're working with birth parents who often have their
own history of trauma.
It's a longer intervention, but it also addresses the parents
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trauma. So in working with birth parents, we recommend using
child-parent Psychotherapy, which again is sort of like preschool
and down.
From kids 227 parent-child interaction therapy, especially
for kids with disruptions designed for kids with disruptive
behavior. And we're actually have a grant that we're submitting
which is also looking at brain changes and changes in attachment
and how that relates.
So the intervention may change depending on the age and also
the living situation of the child.
So the ABC attacked by people catch up break for kids who
are in Alternative Care and that's going to be there.
If you're working with reuniting a child with a birth parent,
I recommend child parent Psychotherapy which takes a two-generation
approach to dealing with the trauma or children who are kind
of preschool to age 7 or so.
The parent-child interaction therapy is very effective in
both improving the parenting the attachment relationship
and disruptive behaviors.
question Only works if you're doing it do it, right.
So the child Traumatic Stress Center treats about a thousand
kids a year.
We provide childcare and Psychotherapy parent-child interaction
shirt therapy trauma-focused CBT dialectical behavior therapy
new now started truck providing cognitive behavior therapy
for parents as well exposure therapy and the like so some
of the things that aren't Clinic does that I think helps
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keep Fidelity as well as maintain Communications.
Is we do have bi-weekly group clinical meetings and we're
blessed in that we have Trainers for each of those models
that are certified at our site.
And so it's an opportunity for conditions 8 kind of learn
and brainstorm from one another because you can have but
things come up and so that it's an opportunity to a make
sure people are staying in terms of fidelity and check things
but also to kind of have that impact with one another the
other We also have self-care and at least a monthly basis
where they'll be a special activity run through the clinic
which is some variation of self-care and you know sort of
it's embedded into our discussion about the nature of the
work. All right, they Medicaid or they are almost entirely
Medicaid. Okay.
So those are our kids.
Yeah and very large numbers and I have to say Baltimore Child
Protective Services has shocked me.
I'd like the cases that keep coming through, you know, part
of what I have to do is just like make I mean people are
not looking at the records.
It's like, you know, they're planning reunification on a
child who had burns from here down acquired three surgeries
were maybe even more than that end.
The worker couldn't tell me they weren't sure if it was ever
substantiate and plus they get into feeding tube because
they were malnourished.
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I don't think the child was so young.
I don't think my mom was some teachers.
Can you look up those records?
Guess what?
Mom had been substantiated in this poor kids been subjected
to visits the whole time and he started to think about the
unification. Even so yes, a lot of our kids are whole nother
issue. That's a whole other issue.