So the title of the talk today is the science of risk and

file:///C/Users/rmenard/Desktop/CC%20Videos/science.txt[3/3/2021 14:00:51]

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


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.


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


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?


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.


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.


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


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


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.


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


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


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


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.


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


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.


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


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


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


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.


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


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.


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


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


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


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


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


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


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


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


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.


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.

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