Keys to Overcoming Trauma and Building Resilient...

unm health sciences institute for resilience, health, and justice

Keys to Overcoming Trauma and Building Resilient Futures

Family Infant Toddler Program Annual Meeting13 june 2018

andrew hsi, md, mphdirector institute for resilience, health, and justiceprincipal investigator FOCUS program at UNM CDD

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Objectives for Presentation

At the end of this presentation, attendees will design collaborations for:• Epidemiology of prenatal substance exposure,• Focused home based early intervention• Interventions to reduce developmental effects of exposure• Evaluating connection of ACEs to developmental risks• Concepts of resilience for parents and infants• Planning integrated survivor friendly care:

• Individual reduced risks of disparate health outcomes• Ameliorating effects of Adverse Childhood Experiences• Two generation models of survivor friendly care 2


Expression of Gratitude

• NM Fit Program teams• NM Department of Health• FOCUS and ADOBE teams at UNM HSC

• Principals when we started in 1990• Medical providers need to care of infants with

exposure• Home based developmental services• Support all parents, no discrimination• Understand how to engage families at risk

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Conflict of Interest Statement• No financial interests to disclose• No actual families are depicted in this presentation• No expertise in your specific communities• The experiences of trauma do not define future destiny

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Cheryl referred from hospital19 years oldGave birth to LorettaUsed heroin in pregnancy


Cheryl Referred to FOCUS Program• 3rd Pregnancy, older child not in Cheryl’s care• Gave birth to Loretta

• Heroin use in first 15 weeks• Opioid replacement Subutex• Term birth, no problems

• Loretta had withdrawal• 14 day treatment for NOWS• Discharged off medication• Eddie, her father, present for care

• Outpatient care starts• Detailed history from Cheryl 5


Cheryl’s Life History with ACEs: Health Risks over The Lifespan

Cheryl’s life events

Adverse Childhood Experiences

Disrupted Neurodevelopment

Social, Emotional, & Cognitive Impairments

Adoption of High Risk Health

Behaviors

Disease, Disability

Risk Early Death

6Dee, Cheryl’s mother used heroinJay, Cheryl’s father left family

Sexually abused in relative’s home

Neglected and had behavioral issues

Cheryl had no mental health care

Jay abusive to Dee in front of Cheryl


Clinical Picture of Loretta’s Altered Neuroreceptors

• Problems from prenatal opioid exposure:• Loretta hypertonic from dopamine depletion• Hard to handle, fussy, low regulation capacities• Feeding problems, hard to latch on breast• Spits up after taking bottle of expressed breast milk• Cheryl and Eddie at the limits of their parent experience• Cheryl feels stressed, has trouble with regulation

• In past she turned to opioids or benzodiazepines to numb• Eddie feels angry, has trouble with regulation• They come to FOCUS clinic

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Clinical Interventions• How would you prioritize the needs

for Loretta? Cheryl? Eddie?• Cheryl most activated by feeding

• Support her breastfeeding• Decrease stimulus around Loretta to

help latching• Observe feeding in exam room• Discuss ways of managing stress• Guidance around sleep• Screen for depression• Help Cheryl develop regulation skills

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Reducing Stress for Family• Loretta

• Swaddling to help decrease motor stimulus• Better quiet alert, more organized nursing

• Eddie; connect with counselor, parenting group

9Ntd.tv


Cheryl and Eddie Enroll in FOCUS• Assign home based early interventionist

• Home visits at least monthly to support Loretta’s development• Observe family in motel room, organize calm area for baby• Model capturing infant attention, demonstrate mirroring• Demonstrate infant massage, cue reading for touching infant

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Fetal position at 28 weeks

Nilsson RM, webmd.com


Effect of Altered Dopamine Systems• Abnormal inhibition to muscle contraction, high tone

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When dopamine effect reduced,

decreased control of body

movements, baby is stiff


FOCUS and Prevention of ACES• Reduce parental stress by supporting Loretta

• Continuing well child care, monitor head growth• Demonstrate supported tummy time in clinic• Model language interaction with infant and parents• Provide parents with specific supports for Loretta

• Psychologist on clinic team to do brief counseling• Primary care appointments for Eddie and Cheryl• Medication assisted treatment with Suboxone• Stabilize opiate receptors, reduce relapse risks• Medication as needed for depression, anxiety• Stabilize serotonin receptor systems 13


Engagement and Height Change

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0

10

20

30

40

50

60

Birth

3 months

6 months

9 months

12 m

onths 15

months

18 m

onths 21

months 2 y

ears

Height of Baby (in percentiles)

by Clinic Appointment Engagement

Measures

Age of Baby

Standardized Length/Height Parameters (in percentiles) for Babies with Data from Birth to Two Years, by FOCUS Clinic Engagement Measures

Low-Medium N=20

High N=8


Use of Cocaine, Crack, or Heroin by Engagement Level, First Year in FOCUS

15

0

10

20

30

40

50

60

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

HighEngagement

Low andMediumEngagement

Babies’ Age in Quarters

% MothersUsing

Crack,Cocaine,Heroin

Engagement as kept home visits, medical appointments, follow through on developmental recommendations


FOCUS Program Directed at 2 Generation Effects of ACEs

• Loretta’s brain has “deformation” from exposure• Support of infant after receiving treatment for NOWS

• Persistent hypertonia; stimulus response regulation• Neuromotor intervention, supported tummy time• Counters hypertonia in extensor groups

• Model how parents can help• Bring parents to floor to play• Reduce risk of child neglect

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Reduce ACEs Effects on Parents

• Cheryl and Eddie’s brains with deformation• Chronic opioid use changes opiate receptor systems• Also down regulates dopamine, serotonin• Buprenorphine saturates opiate receptors• Stabilizes neurotransmitters, restores equilibrium

• Home based early intervention• Provides concrete support to read infant cues• Supports positive touch to aid development

• Requires parents to change for infant17


Dopamine Pathways and Learning

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Anterior cingulateEssential for

memory formation leading

to learning


Infant Development at Risk• Abnormal inhibition to external sounds after exposure

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When dopamine effect reduced,

decreased memory

formation


Expressive Language After Exposure

• Delays between 1 and 3 years of age• Primary exposure• Poor dopamine

inhibition• Environment noisy• Affect extreme or

speaks in monotone

• Receptive normal

• Research on language• Higher income homes

• Greater numbers of word use• More specific positive praise

20 times per hour• “I like how you ate bananas.”• Open ended language• “How did you draw that?”

• Predicted 8th grade progress

• Model in FOCUS work 20

Hart and Risley, 1995, Meaningful Differences in the Everyday Experience of Young American Children


Sequence of Developmental Skills

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Sensitive period for appropriate stimulation

Ideally, parents are present and prepared to fall in love with infant at critical times


Developmental Sequences in Loretta’s Brain

• Skills build over first years of life• Home based case management

• Helps Cheryl in her home with Loretta• Model support for infant development• Model emotional regulation, expressive language skills• Essential skills for developing attachments

• Help build parents’ learning, dopamine responses


Overview

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•“You can’t learn empathy from something that can’t empathize – and without reciprocity and interaction during teaching, language learning is severely impaired.”

• M Szalavitz, B Perry Born for Love, 2010 HarperCollins Publishers, New York, NY, page 216


FOCUS Aiding Parenting• Home based case management

• Helps Cheryl in her home with Loretta• Model support for infant development• Model emotional regulation

• “Educating” a parent is okay:• But not enough to achieve normal

child development• Modeling support for Loretta for

Cheryl and Eddie• Services to meet needs not based

on curriculum24


Development Supported by Parental Emotional Development• Loretta’s ability to master reading depends

on:• Supportive emotional environment• Mastery of early skills to provide foundation• Repeated opportunities to practice• Growth of self-regulation• Supports advanced skills like reading• Positive reinforcement by caregivers• Can’t skip steps

• Growing skills create attachment• Changes dopamine in Cheryl and Eddie’s brains 25


Assets Relevant to 3‐5 Year Olds• External assets to the child

• Support from family, other adults, neighbors, and community• Empowerment; valued in community, safety, service to others• Boundaries and Expectations made clear• Constructive use of time for age

• Internal qualities in the child• Committed to learning age appropriate• Positive values; communicated from universal family values• Social competencies appropriate for age• Development of positive identity; personal power, self-esteem,

sense of purpose, positive view of personal future

• Sample of guidance for appropriate parenting 26

Copyright © 2005 by Search Institute, search-institute.org


Recovery of brain dopamine transporters in chronic methamphetamine user after prolonged abstinence.

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OverviewHumans are the product of nature and nurture. Genes and experience are interdependent. Genes are merely chemicals and without “experience” – with no context, no microenviromental signals to guide their activation or deactivation – create nothing. And “experiences” without a genomic matrix cannot create, regulate or replicate life of any form. The complex process of creating a human being - and humanity – requires both.

BRUCE D. PERRY “Childhood Experience and the Expression of Genetic Potential: What Childhood Neglect Tells Us About Nature and Nurture.” 2002 Brain and Mind 3: 79–100

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Health as Sum of Neurotransmission• Chronic changes of brain

signaling systems• Opioid substance use disorder;

changes opiate receptors• Down regulation of dopamine

signaling• Decreases memory and learning• Requires larger stimulus to “feel

normal”

• Life experienced through brain chemistry 29

“I think; therefore I am.” ― René Descartes, 1596-1650


Connecting Brain Capacities

• Cognitive, emotional, and social capacities• All woven together throughout the life course• Brain is a highly integrated organ with multiple functions

• Capacities operate in coordination with one another• Emotional well-being and social competence provide

• Strong foundation for emerging cognitive abilities• Organize development of brain architecture

• Recovery of normal neurotransmitter in synapses

“I remember, therefore I think, therefore I am.”


Improve Serotonin Levels for Treatment of Depression, Anxiety

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• Post partum depression• Chronic depression

• Changes in serotonin signaling systems in substance use disorder• Affects mood, sleep, anxiety• Low levels cause persistent sadness

• Serotonin affecting medications• Frequently prescribed• Not physically habit forming• Increase availability of naturally

produced serotonin


ACEs: Relative Risks of Health Behaviors Associated with Risks for Early Death

ACE Score

Alcoholism*

IV Drug Abuse*

Attempted Suicide*

0 1.0 1.0 1.0 1 1.9 1.0 1.8 2 2.1 2.5 4.0 3 2.7 3.5 4.0

4 4.5 3.8 7.2 >5 5.1 9.2 16.8

* 0 adverse events set as standard risk 32


Cheryl’s Life History with ACEs: Health Risks over The Lifespan

Cheryl’s life events





Behaviors

Disease, Disability

Risk Early Death

33Dee, Cheryl’s mother used heroinJay, Cheryl’s father left family

Sexually abused in relative’s home

Neglected and had behavioral issues

Cheryl had no mental health care

Alcohol and marijuana age 12, self medicating, no treatment

Sports injury led to prescription opiates age 15, then heroin use

3rd pregnancy within 4 years

Hepatitis C status pending

Jay abusive to Dee in front of Cheryl


Signals Towards Better Health

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Behaviors

Disease, Disability

Start replacement therapy, opiate receptor protection

Implement harm reduction practices,Discuss alcohol, tobacco, marijuana use

PARTICIPATION in therapy identifies Successes

Consistency with appointments, takes medications

Allows home visits, participates in developmental support of child

Fills prescription for naloxone to prevent overdose


Drawing on Resilience to See the World Through Loretta’s Eyes

35Adverse Childhood Experiences



Parent attends education, job entry, goes to work regularly

Build normal emotional and intellectual development for

their infant

Creates safe loving home for infant

Develops support group of safe people

Advocates for development of infant


Shonkoff, Center for the Developing Child

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Concepts of Resilience

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• Achieve outcome greater than expected• Resilience from cohort study Werner, et al

• Personal qualities; personality, talent• Someone who gave child unconditional love

• Adults as gatekeepers• SUD as chronic recurring disorder

• Parallels to cancer; presentation, remission, relapse• Therapy may cure, or achieve remission, lengthen life• Anticipate relapse; support parenting

• “How did you manage to arrive today with your child?”


Characteristics of Survivor Friendly Primary Care for Families

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• Trauma-informed model of care • Expect probable underlying mental health challenges• Recognize relapse potential of substance use disorder• Avoids depersonalizing and stressful interactions that can

themselves be traumatizing for patients

• Survivor Friendly Primary Care for families• All of above and• Engage individual in specific view of health/function

• Congratulate for making it to clinic• Achieve continuity of care, build trust


Goal Question for Cheryl and Eddie

• What do you want for your child?• Answer: Graduate high school!• Questions

• What do you need to be there?• What will we do at this visit?

• Create small daily changes• Draw on resilience for health

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Shonkoff, Center for the Developing Child

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Issues of Recovery as Family

• Expect parents to make changes• Become appropriate advocates• Normalize daily activity schedule• Take medication daily• Attend counseling, learn new ways

• Apply learning to tomorrow• Requires system changes

• Build willingness to engage with family• Commit to continuity with providers 41


Brain Altered by Prenatal Exposure to Drugs

Connecting the Intervention Concepts Across Generations

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Adverse Childhood Experiences; NOWS

Regulated Neurodevelopment

Social, Emotional, & Cognitive Skill Acquisition




Loretta

Cheryl and Eddie

Adoption of HealthierBehaviors

Health Seeking Status

Collaborative Intervention to Reduce Generational Impact of Adverse Childhood Experiences

Adoption of Health-risk

Behaviors

Disease & Disability

Reduction of Health-risk Behaviors

Healthier Status

Healthier Lives

TolerableStress


Loretta Will Have Lowered Risk Health Behaviors Associated with ACEs

ACE score Alcoholism IV Drug Use Attempted Suicide

0 1.0* 1.0* 1.0*

1 1.9 1.0 1.8

2 2.1 2.5 4.0

3 2.7 3.5 4.0

4 4.5 3.8 7.2

≥5 5.1 9.2 16.8

* 0 adverse events set as standard risk of 1.0

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Health as Balance

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A mother found meth in her car. She’d been stable for many months. She used and felt bad. Consider all the times she’d been around drugs and didn’t use. If she had come across drugs 99 times before and used once, how do we evaluate her progress?


Quotes Regarding Desire in Recovery• “So, if desire cannot be turned off or seduced away

from addictive goals, immediate goals, then it has to be fastened to goals incompatible with addiction• Freedom from suffering• Achievement of life projects• Access to loving relationships• Sense of coherence and self-love”

• “The trick to overcoming addictions is thus• The realignment of desire

• Switches from goal of immediate relief• To the goal of Long-term Fulfillment”

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Mark Lewis. The Biology of Desire: Why Addiction is not a Disease. 2015. Perseus Books


Challenges for Future• What happens to the babies as they age?• Do the parents stay sober? • Developmental challenges persist for those exposed• They will become what our society wants for them• The parents will have the health we support• Long term goal for the family

Parents love and advocate for children

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FOCUS: Key to Building Resilience

• Principals when we started in 1990• Medical providers (some) care for infants with exposure• Some medical providers willing to care for parents• Home based developmental services are standard• Some children better prepared for formal education• Support all parents and infants, some discrimination exists• Incomplete understanding of how to engage families at risk

• Fund data systems for long term education outcomes• Consider the meaning of child protective services• Healing or prosecution will require consensus 47


Recovery As Experienced by Persons in Recovery • Handling negative feelings without use of drugs or alcohol• Being able to enjoy life without drinking or using drugs like I

used to• Being honest with myself• A process of growth and development• Reacting to life’s ups and downs in a more balanced way

than I used to• Taking responsibility for the things I can change

• (LAKaskutas. Elements That Define Recovery: The Experiential Perspective. J Stud Alcohol Drugs,75, 999-1010, 2014)

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Health as Existence in Present

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Resources/references• http://www.drugabuse.gov/• http://www.samhsa.gov/• Lakaskutas. Elements That Define Recovery: The Experiential Perspective. J

Stud Alcohol Drugs,75, 999-1010, 2014• Mark Lewis. The Biology of Desire: Why Addiction is not a Disease. 2015.

Perseus Books • The Compass of Pleasure: How Our Brains Make Fatty Foods, Orgasm,

Exercise, Marijuana, Generosity, Vodka, Learning And Gambling Feel So Good (David J Linden)

• The Addict: One Patient, One Doctor, One Year (Michael Stein)• In the Realm of Hungry Ghosts (Gabor Maté)• https://www.drugabuse.gov/videos/dr-nora-volkow-addiction-disease-free-

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