1 What is neglect; a medical perspective and the neurobiological modelJo Tully VFPMS April 2017 Child neglect is as we have heard common, chronic and pervasive. It requires a multidisciplinary approach to management and intervention and it requires people to first and foremost recognize the problem. There is a general feeling (and correct me if I’m wrong) that it is all a bit too hard – where as clinicians, do we start? Can we really make a difference? I think that we can. What I would like to cover over the next 40 minutes or so (and obviously this is a huge topic) is an overview of theoretical concepts around neglect. I want to give you a framework within which you can consider these kids with the hope that you can then feel more empowered to make strong recommendations in order to make significant improvements in these kids’ lives. After lunch we are having a more practical session about evaluating neglected children and I hope you can bear in mind what I am going to cover over the next 40 minutes or so and perhaps understand its relevance to all of us who assess children. A clear conceptual understanding of the nature of neglectful and EA behaviours can assist in identification and understanding and therefore in planning and targeting effective intervention strategies.

2 CA and N are not new problemsCA and N are not new problems. Charles Dickens as a social commentator used the appalling situation that many kids lived in in 19th C Victorian Britain as a background to many of his novels. Many changes in society have taken place to improve the situation for children since those times but we have new challenges now – the disintegration of the family unit, separation, migration, the increasing problem of drug and etoh abuse and of course IPV. Our knowledge of, the early recognition of and response to physical abuse have undergone dramatic advances but the approach to EA and neglect lags behind. EA and neglect causes substantial harm to a child’s development and functioning, often persisting into adult life. Despite this there has been a suboptimal professional response to the problem – mainly through problems with definitions, thresholds and evaluation and intervention strategies.

3 Neglect can be fatal

4 “when was the last time he said something to you?”“Last night. Something strange with him. He was saying “help, help” Could you pick me up please?” I turned him over to a comfy position and I helped him. I asked him what would you like? – ‘could you get me a glass of water’ – sad kind of talk” Just as PA can kill especially in infancy, so can neglect. In 2012 we saw a 8 year old boy in our service who was the brother of a 5 year old boy who had just been found dead at home. The boys lived in appalling squalor, had never been to school, were unimmunized, the older boy cared for his brother because as his parents said “the boys, they just do there thing and we do ours”. The younger boy got sick shortly after cutting his foot on a rusty can and his brother was asked about that night. Shortly after this this 5 yr old boy died without any love, care or attention form his parents who were in the house at the time and failed spectacularly in their duty to even know their son was sick let alone seek the urgent medical care that he needed.

5 Types of abuse substantiated across Australia 2014-15EA and neglect are the commonest substantiated harm types across Australia. Almost 70% are within the combined emotional abuse plus neglect categories. EA often considered with neglect and traditionally has been so. The EM of children might be labelled as neglect rather than as EA. I believe there is a strong argument that EA should really be considered as its own subtype and you will see why later. An argument exists that EA exists in all forms of child maltreatment so perhaps it should be far higher than the 40% shown here for I am going to include some of the theories behind the EM of children in this talk because it is so entwined with the abuse of children generally and because its negative outcomes are significant. Although neglect so common and its impact so great, it is probably the least understood form of child maltreatment. It has lacked a consistent definition and uniformly applied classification system and has been plagued with issues of thresholds and what constitutes harmful neglect. Because there is no single cardinal event but a series of chronic insidious events intervention and professional response has been challenging and often sub-optimal. What I want to give you through out this talk is a theoretical way of approaching the problem of child neglect in order to clarify some of these issues and remove some of the mysteries surrounding neglect and emotional maltreatment. Nursing Orientation 2016

6 Health & Wellbeing Love Warmth Shelter & clothing Food EducationProtection/safety Play & social connection Before talk about what children don’t have need to talk about what they need – optimum environment. This is what we know that children need for optimum physical and mental health and wellbeing. These are universal and transcend culture and ethnicity. They need love, nurturance and attachment. They need physical basics – food, warmth, shelter. They need opportunities to develop, learn, play and socialise. They need access to medical treatment and physical safety as set out in the UN charter rights of the child. Deficiencies in any of these areas constitutes neglect and if ongojng is likely to result in maladaptive outcomes for the child. Medical treatment Emotional enrichment, moral/spiritual guidance/stability Appropriate stimulation

7 The sub-optimal professional response to neglectDefinitional difficulties – actual harm/likely harm…? Threshold uncertainties Repetitive, sub-threshold events No clear critical event to trigger PS’s response Chronicity results in greater harm Often multiple reports involving many children Lack of evidence about management Lack of evaluation of intervention strategies I have talked about a sub-optimal professional response to neglect. Why is this? Why do we find it relatively easy to intervene when a child has a bruise on his or her face but when a child is demonstrating severely maladaptive behaviours, not turning up for appointments, FTT etc etc it can take months or years to intervene. I big problem that protective services face is around the definition of harm and the legal requirement for harm to be demonstrated. Waiting for harm to occur could preclude protective intervention when there is evidence of harmful interactions which have not yet caused harm (very common because of chronic/cumulative nature of acts and consequences). Child’s rights approach states that waiting for harm to occur is against the best interest of the child. There is a general lack of evidence about the best Mx strategies and the effectiveness of various interventions. What this has produced is a type of paralysis – an “its all too hard” feeling that has not served the best interests of the children involved.

8 Neglect – WHO definition“The failure to provide for the development of the child in all spheres: health, education, emotional development, nutrition, shelter and safe living conditions, in the context of resources reasonably available to the family or caretakers, and causes or has a high probability of causing harm to the child’s health or physical, mental, spiritual, moral or social development. This includes the failure to properly supervise and protect children from harm as much as is feasible.” WHO Report of the consultations on Child Abuse Prevention. Geneva, Switzerland. March 1999 Consequences for child rather than parental behaviour….. Intention to harm not required So thresholds is one problem, definition has been another. The entity goes by different names in different countries, jurisdictions and in the literature. There are medical and clinical definitions, social service definitions, legal and judicial definitions, and research definitions of child maltreatment. Definitions of child maltreatment reflect cultural values and beliefs. Behaviour that is considered abusive in one culture may be considered acceptable in another (e.g., corporal punishment). Parental behaviour that is appropriate at one stage in a child's development may be inappropriate at another stage of development (e.g., the level of supervision needed for toddlers versus adolescents). Although perpetrator intent to maltreat a child is often a useful indicator of child maltreatment, there are a number of instances where abuse or neglect can occur even though the perpetrator did not intend to commit it (e.g., neglectful parents may have had no intention of neglecting their children. There are many definitions out there this is the WHO definition which is now widely accepted. Traditionally the focus has been on acts of omission by a caregiver with the focus of ‘blame’ being on that caregiver in failing to provide. This focus on omission (or commission in some cases of emotional maltreatment) is similar to the approach we take with physical and sexual abuse and is consistent withneglect being a form of maltreatment. However, child neglect is very complex and a more expansive definition has been proposed that takes into account what is known as the ecological approach to neglect – focusing on the child rather than the caregiver – and defining neglect when the childs needs are not met for whatever reason. The child is the focus of concern and attributing blame is not the most constructive way forward. It is important to recognise that the intention to harm is not required to meet the definition.

9 Over-riding definition neglectPersistent, non-physical harmful interactions with the child by the caregiver, which include both commission and omission Glaser 2011

10 Concepts surrounding neglectWhat I am now going to talk about is a more theoretical approach to neglect and EA. Much of the work I am going to present here has been done by Danya Glaser who has proposed a conceptual framework for dealing with EA and neglect in order to better define, ‘diagnose’ and target interventions.

11 Ecological model of child neglect– the requirementsSecure attachment to consistent caregiver Maternal physical & mental health Income Parenting style Parental health Parental education Child Society Family/caregiver Community Crime Overcrowding Green spaces Policing Education Family supports Economics Population income Employment Immigration Cultural attitudes Racism Conflict So firstly, some concepts surrounding neglect. What is presented on this slide is a model of what is known as the ecological perspective or model of child neglect. This underpins the theoretical work and the approach to assessment and intervention. The ecological model proposes that neglect has a complex multifactorial aetiology and that there is a context within which caregivers interact with the child. Allows the emphasis to shift from one of caregiver ‘blame’ to acknowledgment of the myriad of social factors that contribute to the neglect of a child and that a child exists within a wider context and that this context includes child factors but also family factors and factors within the community the family live in and the wider society – the environment. Difficulties in these areas effectively constitute RF’s for neglect and EA. This slide illustrates the minimum’ requirements’ that a child and a family need for effective functioning.

12 Ecological model of child neglect – the risk factorsAge, prematurity Behaviour Disability/delay Planned/unplanned Chronic illness Mental health esp depression Stress Abuse history Substance abuse Domestic violence Young age, single parent Isolation, transience Low education Child Society Family/caregiver Community Chronic poverty High unemployment Low education Limited green spaces High crime/drug rates Cultural attitudes Low income High unemployment Poor access to health Underfunded child welfare system This is the ecological model again but presenting the potential RF’s in each area that increase the chance that a child will be neglected. Social and community RF’s refer to the interactions that occur between the family and their immediate environment – poverty, unemployment, immigration issues, poor access to education, high crime rates and inconsistent policing for example. Research and experience suggests that there are a number of caregiver RF’s that we will all be familiar with which are associated with and often predispose towards EA and neglect. They present what could be called a “toxic mix” – IPV, drug and etoh misuse, mental; health difficulties. It is not uncommon for these RF’s to co-exist for any one child. We know that neglectful parenting will not be overcome while drugs are the focal point in a parents’ life but overcoming substance abuse is even more challenging if you live in an area where drug use is common. This musn’t be used to “explain” the child’s difficulties and preclude further action or Ix to be undertaken. Research suggests that it is the interaction of these Fx’s that determines whether neglect will occur – eg poverty alone does not necessarily mean that a child will be neglected, but if the caregiver also has poor problem-solving skills and the child has chronic disability then the interactions may result in neglect. Most children who live in poverty are not neglected. However also imp to consider protective/resilience-promoting Fx. 2 children exposed to same neglectful environment will respond differently. Individual factors within the child – age, temperament, genetics, resourcefulness etc Single most important Fx in this shown to be the presence of adult in child’s life who can provide emotional support and stability – eg grandma, uncle, aunt, teacher – a stable non-maltreating person Need to identify that person – can use in intervention strategies. Dissecting out all these factors is challenging and time-consuming but is essential to adequate intervention. Remember resilience-promoting and protective factors

13 Ways of thinking about neglect – ‘Tiers of Concern’Tier 3 – child’s functioning of concern Tier 2 – harmful child-caregiver interaction Tier 1 – caregiver risk factors This ecological model brings us to consideration of Tiers of Concern. The normal process when considering a vulnerable child is that a set of concerns arise. Information in relation to those concerns needs to be gathered. Information gathering about children and families is often difficult to gather and complex. Once gathered it can then be organised into what we call tiers of concern. This allows us to assess risk. At the centre is the child’s functioning which is often the stimulus or presenting feature for the process. The outer tiers are contexts for the inner tiers. There may be reciprocal or bi-directional interactions between the tiers. Difficulties in tier 2 must be present for the recognition of neglect (or EA as we will see later) but there doesn’t have to be difficulties in all the other tiers. Without difficulties in tier 2, the functional difficulties of the child (be them behavioural, developmental, social) cannot automatically be attributed to neglect. Eg parents might be erroneously held to account for the difficulties their child with ADHD experiences – attributed to EA because parents struggling to manage behaviours. Child treated, problems resolve OR parents might then denigrate child further etc and EA verified. Tier 0 – social and environmental risk factors Glaser, D Child abuse and neglect 2011

14 The 3 Axis Types - classificationThresholds – degrees/severity – continuum of harm, chronicity, urgency of intervention, type of intervention Outcome – likelihood of harm, harm already present, defining the harm – the “arrow of time” Danya Glaser 2011 So while the ecological model gives us an overview of the problem and gives us a risk factor and vulnerability structure, we as practitioners involved in evaluating these children need a framework for evaluating them. How are we going to make sense of the factors present, how are we going to organize them in order to provide a clear opinion and pathway for intervention. How are we going to make steps to improving these kids’ lives? This and this is one way of approaching it. e and provide evidence for if you like the presence of neglectful patterns. It can be useful to consider these 3 axis of neglect and be able to make clear evidence-based statements in relation to all 3 axes. Types we have mentioned and will review in the next slide. Severity – measured by intensity and chronicity but also considering child resilience, protective factors plus other risk factors. Outcomes – relates to harm. The Q of whether harm has to be demonstrated or likely is somewhat contentious but the concept and the harm assessment needs to be in some way explicit

15 Types/categories of neglectCategory Example Physical Inadequate/inappropriate; Food Clothing Warmth/shelter Hygiene/personal care Environmental Unsuitable/unhygienic, dirty, cluttered, hoarding Restricted access to suitable play/learning environments Developmental/educational Failure to provide tools/opportunities for learning Failure to enrol/attend school, erratic attendance Medical/dental Failure to provide proscribed medical/dental needs Failure to heed signs of illness or follow instructions Supervisory/abandonment Failure to supervise, suffers harm. Carer whereabouts unknown. Emotional Failure to provide reliable responsive care

16 Thresholds Continuum of child/caregiver interactionCan conceptualise parent-child interaction as a continuum of desirable-undesirable child-caregiver interaction. Where to place the cut-off between undesirable and what is harmful requiring intervention? Significant harm is defined as the ill-treatment of the childand/or impairement of the child’s development which is attributable to the care given to the c hild The blurred lines the grey area exists between the undesirable and harmful parent-child interactions. And this is really why this field has suffered from problems with timely intervention and difficulties with mx. And why it is so important to be able to understand the concept of Harm in relation to neglect and EA and to be able to categorize and clearly define Harm in a timely manner. When does sub-optimal parenting become neglect? This is when harm has occurred. The point of intervention is a challenging because we are dealing with something that is not a discrete event . The threshold is reached when the continued viability of the child-caregiver relationship is regarded as unacceptable without intervention. However there is an argument that neglect needs to be defined and diagnosed when there is a high likelihood of harm occurring – before harm is manifest. Creates difficulties in the legal arena. Harm is important in gauging severity, assessing therapeutic progress and in goal planning. Thresholds indicate when intervention is required while severity indicates the urgency and nature of the intervention required. Severity influenced by intensity of maltreatment and effects on child. Satisfactory (“good enough”)  Undesirable  Harmful “the ill-treatment of the child and/or impairment of the child’s development which is attributable to the care given to the child or likely to be given to the child…not being what it would be reasonable to expect”

17 Outcomes No current or future harm likely –Undesirable behaviours/interactions… Child FIRST referral, supports in place, monitor No current harm, future harm likely Important group but no legal remit Current harm but no future harm – single adverse act…might be catastrophic Current and future harm Clearly state harms and relate to caregiver-child interactions What is the likelihood of harm occurring? Has it already occurred? The arrow of time – watching these kids, following them up with respect to development, growth, learning, behavior. Can be very powerful tool and provide a strong message to protective services and the courts in terms of placement of children/reunification attempts etc. If a child is removed from a neglectful and EM environment and placed in a secure nurturing foster placement and we can demonstrate improvements in behavior and development and growth that should provide a powerful message to say perhaps that child should remain there? Chloe’s case eg? It is important to have an understanding of the harmful effects of the different types of neglect/EA in order to be able to make clear statements as to likelihood of harm. We know that child malRx is harmful but we need to figure out the extent of the harmful interactions and be sure that the harm observed is attributable to the interactions (eg ADHD, ASD) – those tier 2 interactions. You can make some reasonable, theoretical based statements relating to the likelihood harm occurring to this child if she is exposed to xxxxxx.

18 Cumulative harm Cumulative harm is experienced by a child as a result of a series or pattern of harmful events and experiences that may be historical, or ongoing, with the strong possibility of the risk factors being multiple, inter-related and co-existing over critical developmental periods Cumulative Harm: A conceptual overview Vic Gov DHHS CH is the existent of compounded experiences of multiple episodes of abuse or layers of neglect and the unremitting daily impact on the child can be profound and exponential and cover multiple domains. CYFA 2005 creates a strong authorising environment to recognise and address cumulative harm when considering child safety and the Best Interests principle of the act stats that the effects of cumulative harm should be considered when making decisions or taking action by courts, CP or community services.

19 Cognitive, developmental and psychosocial outcomesDevelopmental stage Cognitive, developmental and psychosocial outcomes Infancy and preschool Anxious attachment Anger, frustration, decreased problem-solving skills Developmental delay Primary school Aggression to or withdrawal from peers Often disliked Attention difficulties – ADHD, ODD, ASD High rate repeating years, absences, lower grades Adolescence Juvenile delinquency Absconding from home Arrests for violent crime Prostitution Drug abuse Personality disorders/mental ill-health Decreased high school completion Adulthood Lower IQ’s Employment - <7% in professional employment Crime These are the psychosocial poor outcomes. I am going to talk to you more about these after morning tea but they are significant both to the individual and to society. These domains of negative outcome are greater for neglect and EA than for PA and SA. This is probably in some part because of the difficulties with intervention and Mx strategies.

20 Neglect and substance abuse“Parental drug use is one of the most serious issues confronting the child welfare sector in the past 20 years. The child welfare system, drug services arena, judicial system and the community at large are failing to cope with the increasing culture of illicit drug use in Australia and failing to address its impact on the children of parents who abuse drugs”. Neglect in all spheres plus abandonment – prison terms, death from OD (>1000 children from heroin OD death 2000) Involved in fatal neglect (Victorian Child Death Review Committee 2003) The child is often ignored (similar to FV?) The Child and Family Welfare Association of Australia 2002: 9

21 Noxious Neglect; the neurobiology of neglect and its effects on the developing brainIntroduction to topic – over the past several decades there has been an increasing interest in the effects that early life experiences have on the way the brain develops and the way the body responds to stress. Increasing evidence is emerging that neglect and abuse – adverse early life experiences – shape the structure and function of the brain and the way in which the body responds to stress in a way that can explain many of the maladaptive behavioural and psychological sequelae of abused children that we are familiar with. This whole topic has become known as the neurobiology of neglect and abuse and I am going to try my best to explain it to you over the next 40 minutes or so. Its a fascinating topic and really worth knowing something about because it gives us a greater understanding of the effects of trauma and of the importance of timely effective intervention – which we know from previous talks this morning is problematic issue when considering the chronic insidious nature of child neglect. Jo Tully August 2016

22 “Good mothering” Knowledge over centuries that infants and young children need;’ Love Good nutrition Stimulation Responsive care Critical period from conception to age 6 years, especially the 1st 3 years of life Lasts a lifetime How does variation in parental care lead to (possibly) lifelong changes in neurobiology and behaviour? At birth human infants are the most helpless of all the mammals with a protracted period of development compared to other species. While this allows for the superior human intellect and reasoning, it also means that the human infant brain is plastic and adaptable and therefore vulnerable. Human infants need love, nutrition, stimulation and responsive care and nurturing in order for their brains to develop properly. These aspects provide critical cues for the later environment in which the infant will live and so its perhaps not surprising that these cues can alter and shape the biology and developmental trajectories. Although capacity for change and learning and re-learning persists through life, many of the developmental changes the brain undergoes in infancy and the first few years of life remain. What this talk tries to explain is just how variations in parental care and the extremes of these (CAN) cause thes lifelong changes in neurobiology and therefore in social and psychological functioning – personality.

23 “The nature of love” Harlow’s monkeys and early attachmentIn the whirl of industrialisation of late 19th century Britain, orphanages were in vogue. Nature trumped nurture in deterministic models of child development. These attitudes persisted throughout the first half of the 20th century. By the 1950s however, western psychological research started to recognise the harm of institutional rearing. Foster care was encouraged in the United States and United Kingdom. During this time British child psychiatrist John Bowlby penned a piece for the World Health Organisation which argued that a mother figure was essential for children’s mental health. In the 1950’s a scientist by the name of Harry Harlow performed a series of experiments on rhesus monkeys in order to try and elucidate the nature of love. Harlow discriminated between physiological and emotional mothering. These experiments became widely known and were instrumental in forming theories on early infant attachment and in shaping policy on child-rearing, protective intervention placements and adoption. Harlow concluded that nurture was more important than nature and that attachment was closely associated with critical periods in early life after which it became increasingly difficult to reverse problems created. These experiments were widely accepted to prioritize psychological over biological parenting. Harlow 2 experiments; 2 sets of monkeys with 2 mummies – wire and cloth. Both had milk. All infant monkeys drank from either but spent the rest of their time clinging to the soft cloth mother. Even if all the milk was provided by the wire monkey, the infants only clung to the cloth monkey. 2nd experiment – infants only had the wire monkey or the cloth monkey. Both sets drank equally and grew equally but the wire set behaved differently – when frightened the cloth babies ran to the cloth mother and rubbed against them and calmed down. The wire babies did not run to their wire mummy but threw themselves on the floor, screamed, rocked – similar behaviours seen in Romanian orphans for eg. The theory of a secure base was formed and later elaborated on by Bowlby in his theory of attachment. Also conducted experiments on “better late than never ‘ theory – removed infants from a mother altogether and raised in isolation – permanent social and behavioural changes. Identified critical periods by subjecting them to various periods of motherlessness. When emotional attachments were first established was the key to whether they could ever be established at all. This early work demonstrated the effects of neglect – what we can now go some way towards is explaining them. Harlow’s monkeys and early attachment Critical periods Importance of ‘psychological’ parenting over ‘biological’ parenting Work in primates replicated since

24 Neurobiology -what do we mean?The interplay between nature and nurture How nutrition, care and nurturing directly affect wiring pathways of the brain in early life How parental nurturing in early years has a decisive and long-lasting impact on development, learning, behaviour, emotional regulation and health How negative experiences in early years, including neglect are likely to have sustained effects We all intuitively recognize that CAN is bad for children. Living in an environment of fear, stress, pain, deprivation, uncertainty must we feel be bad and bad for children’s brains and bad for their development. There has been a long-running nature-nurture debate; are we a product of our genes or our environment? The simple answer is both obviously – genes and experience are inter-dependant. Genes are merely chemicals and experience guides these chemicals. Neurobiology is the explanation of this process and is particularly important in the discussion of early life adversity because it shows us how critical early life brain development is and how closely linked to experience this development can be. What this explains is what we have known for centuries - that parenting is critical to the development of the individual.

25 What is the biological model of neglect?Biological explanations for emotional, behavioural and psychological effects observed Lasting and ‘transmissible’ effects of child neglect and emotional maltreatment Environmental and genetic influences - the “nature/nurture” debate HOW? Effects on structure and development of brain – - synapses and myelination Effect on the endocrine system - stress Epigenetics Many experiments in non-human primates and rats that have demonstrated adverse effects on attachment and social functioning from abuse and neglect. This adverse functioning has been linked to changes in the structure, size and function of the brain, to variations in hormones related to the stress response and more recently to changes in the epigenetic signaling occurring in the genome. What this gives us is a biological explanation for what we are seeing in these children in terms of behavior, learning and social functioning and may also go some way to explaining what we all recognize as the cycle of abuse –the potential for abusive or neglectful parenting behaviours to be propagated through the generations.

26 Environmental influencesFactors in environment affect pre and post natal development of the brain Prenatal Maternal stress Maternal drug/alcohol use Postnatal Poverty Poor nutrition The “unique environment” Healthcare availability Educational opportunity Stress, extreme deprivation and maladaptive experiences - abuse and neglect Abused and neglected children often have many/all these factors There are several environmental factors that influence brain development one of which is the stress associated with abuse and neglect. Prenatal – no legal mandate to influence maternal behaviour and therefore no legal protection of the fetus –we cannot compel a woman not to abuse drugs, smoke, drink to excess and the baby stops growing and may require early delivery. Stress – delayed motor and intellectual development at aged 2 Foetal alcohol syndrome but also ‘lesser’ neurobehavioural effects - delayed speech and motor development, hearing impairments, slower information processing, memory deficits, behavioural problems. Opiates – stress produced by withdrawal Cocaine – most harmful – reduces maternal oxytocin in hypothalamus – affects developing systems related to reward (dopamine, serotonin, Noradr), affects levels of arousal, emotional regulation, structural development of brain also affected. Children more impulsive, hyperactive, distractible etc. Nicotine – smaller lungs, disruption to NorAdr system, assoc with later antisocial behaviour Postnatal Fx include some of the things we have already talked about as well as the effects of extreme deprivation, stress and maladaptive experiences ie. Abuse and neglect

27 What does abuse and neglect do to these systems?Neglect = absence of critical organising experiences at key points in development Child abuse harmful because Critical period for brain development Set points for activation of the stress axes are programmed Cumulative damaging effect on neurodevelopment – not easy to ‘see’ May be mediated by; Age of child Chronicity and type of abuse Identity of abuser, presence of other stable adults Child maltreatment is harmful in a number of different ways. Not all children are harmed, not all are harmed equally but it is generally speaking damaging to children’s emotional, social, behavioural and educational development. Disruption of critical neurodevelopmental cues can result from lack of sensory experience – NEGLECT – or abnormal patterns of interaction – TRAUMA. Unlike a broken bone the adverse effect on the development of for example ‘empathy’ because of childhood emotional neglect is not easy to see It is not surprising that there will be changes in the brain therefore. There are many different aspects of child maltreatment that help determine how the brain is affected – duration, age, genetic make-up etc. Essential experiences are developmentally different – an infant needs touch, close contact, rocking – a pubescent child does not. The untouched infant may quite literally die. Neglect is more devastating if early and pervasive. If you thinks about infant crying – expects a response from caregiver – affection, soothing, soft words. These strengthen neural pathways and connections involved in social interactions, empathy etc. These are the building blocks of social relationships and attachment. If not done and crying is met instead with being ignored or with harsh punitive words or treatment then these connections don’t develop properly and the child may grow up with a lack of empathy, a lack of understanding of social cues and kindness, an inability to nurture and to understand the pleasure that can be given and received by nurturing loving relationships.

28 The brain, its structure and development and what happens to the neglected brainSo lets now examine each of these factors – brain structure and development, stress system and epigenetics in turn to see exactly what’s happening for these children. This is a well-publicised CT brain image of a normal 3 year old brain and a severely neglected 3 year old brain – obvious marked difference in size. This represents an extreme that we thankfully don’t often see in this country in the 21st century – but I say often because I can think of several examples of severely neglected children that might well have had radiology similar to this.

29 Development of the brainMany capacities thought to be fixed are actually dependent on experiences Development occurs from ‘bottom up’ First some revision about normal brain structure and development. Many of the capacities of the brain that were thought to be fixed at birth we now know are actually dependent on experiences gained in early life. The brain matures and develops in an infant from the ‘bottom up’ – so that centres at the bottom responsible for basic functions are reasonably well-developed at birth and not therefore subject to environmental influence – for obvious reasons! The higher areas regulating emotion, language, abstract and concrete thinking – executive functioning if you like – develop rapidly in these first few critical years of life. Regions regulating emotion, language and abstract thought develop rapidly in 1st 3 years of life

30 Brain cells present at birth, synapses poorly developed Brain development is process of creating, strengthening or discarding neuronal connections 2 million synapses per second in healthy toddler, 100 trillion by 2 years of age Neurotrophins act as mediators secreted in response to neuronal activity which in turn is regulated by environmental input 2 important process in brain development – myelination and synapse development So what we are going to talk about now is brain development. There are a number of different processes that occur during neurodevelopment which is basically the process of creating, strengthening and discarding neuronal connections. Brain consists of trillions (100 billion) of brain cells. In between the brain cells are gaps called synapses. Myelin is a fatty substance that sheaths the nerve cells and allow rapid transmission of impulses from brain cell to brain cell. (eg walking relies on myelination within the spinal cord). Neurotransmitters are needed to cross the synapses (serotonin, Noradr, dopamine). Neurotrophins are secreted in response to neuronal activity. This activity depends on the specific inputs received from the child’s environment. At birth we have most of our brain cells but synaptic development is poor. Synapses present at birth are mostly those involved with bodily functions such as breathing, eating, sleeping. Brain growth maximal in first 3-4 years of life. Some parts continue to grow into adolescence. Some brain cells die off. It is not the cells (gray matter) that grow, it is the nerve processes (white matter) that grows. This leads to growth in synapses. Synapse development occurs at an astounding rate in the early years. This explosion of synaptic development occurs in response to patterned repetitive experiences that refine and sculpt the neural connections. Production of synapses occurs in genetically determined order – smell and vision first, speech later. If this continued throughout all parts of the brain there would be chaos and so based on the child’s experiences some synapses are strengthened but some are gradually discarded. This is known as synaptic pruning. By adolescence this process is largely complete. Neurons that make good synaptic connections survive, those that don’t die. This is the concept of “use it or lose it” The process of myelination also follows this kind of course – the rate of myelination growth is effected by a child’s experiences. If this process of synaptic development is disrupted by abusive experiences then lifelong adverse consequences can result. It is these processes that are dependant upon genes and environment. Disruption of these processes can lead to profound dysfunction.

31 How the brain develops in early lifeBrains are hard-wired to expect certain experiences’ eg speech, vision Synaptic pruning; Create, strengthen and discard synapsis Myelination changes Pruning and myelination sensitive to environmental input ‘Sensitive’ periods during which brain especially responsive to environmental input Plasticity – ability to change in response to repeated stimulation Stage of development Brain system involved Some experiences the brain is hard-wired to expect – vision, speech for eg The processes of synaptic development and myelination are most active in different regions of the brain at different times and require (critical periods) or be sensitive to (sensitive periods) experiences. The term neural plasticity relates to the ability of parts of the brain to change and adapt in response to environmental cues and this remains throughout life and forms the basis for learning. Some parts of the brain like the brain stem have limited plasticity while others have a greater degree of plasticity.

32 Different types of brain developmentExperience expectant DEFICITS/FAILURE in stimuli ie. Neglect/attachment/vision Failure of synapse development due to lack of environmental stimuli – “use it or lose it” (critical periods) May be permanent problems Experience dependent Synapses form in response to positive or adverse stimuli “serve and return” Neural plasticity May adversely colour the child’s world Abuse v neglect Experience adaptive How brain develops is adaptive to environment at time – maladaptive environment – maladaptive development Not pathological but understandable adaptation During synapse development some synapses are strengthened and some are discarded – this is normal development. Our brains prepare us to receive certain experiences and are brains are hard-wired for these experiences to arrive – this type of development is called Experience expectant. An eg of an experience-expectant development would be vision. The brain is so programmed to expect these experiences that if the signals don’t come that part of the brain shuts off and the function may be lost. In animals these are known as critical periods– eg cats - critical periods. Humans we don’t have critical periods but we have sensitive periods. These sensitive periods suggest that within a broad space of time, if the child doesn’t receive certain experiences then the child will not develop that function. The periods are longer and more flexible than in critical periods in animals. The functions that done develop during these sensitive periods may be permanently lost. Eg of a sensitive period and expectant development is the Romanian orphans – no attachment – no stranger wariness . Need to develop attachment by 2-3 years of age –sensitive/critical period for attachment. Permanent disinhibition, risk-taking behaviours. In 1211 Frederick 2nd Emperor of Germany attempted to discover the natural language of God. He raised dozens of children in silence. Gods preferred language never emerged, the children never spoke and all died in childhood. Deprived/neglected of their experience-expectant developmental opportunity. Generally speaking news is better because much of development is what is called Experience-dependent. What is going to wire depends on what is going to fire. ”Use it or lose it” How the brain develops and what wires depends on what experiences the child receives/ subject too. Sequential ongoing adaptation to individuals unique experiences. If child exposed to aggression then part of the brain that responds to aggression will develop and part of the brain that responds to affection/ nurturing will not. No sensitive periods for dependent experiences and so continued learning. More recently a third term emerged -experience adaptive development – brain development is totally adaptive to the child’s environment The brain thinks that this is how life is going to be so I better get on and deal with it. If environment maladaptive then brain development maladaptive but ADAPTIVE to maltreating environment, just not to normal values of society. What this means is that we can understand the behavioural changes in children not so much as a consequence of their exposure but as a perfectly reasonable adaptive response to it.

33 Negative pathways strengthened and developedAbility to respond to kindness and nurturing impaired When considering the effects of these developmental processes in neglected children there are a few important areas of the brain that we need to keep in mind – these are the prefrontal cortex, the amygdala and the hippocampus. The prefrontal cortex regulates thoughts, emotions and actions and as it is a higher centre it matures later in the piece. The amygdala is a small almond-shaped set of neurons located deep in the medial temporal lobe. Its part of the limbic system and is involved in the expression of emotion, fear responses, pleasure. It is linked to aggression. Matures and develops in early years of life. The hippocampus is closely related to the amygdala in the limbic system, there’s 2 of them and they are shaped like a seahorse. They are involved with short and long-term memory and learning and are first to be affected in Alzheimer’s disease.

34 Effects of neglect on development of the brainEffect on child Brain structure and function Learning and memory, PTSD Inter-hemispheric communication Motor & executive function – correlation with IQ and brain size Behavioural, cognitive and emotional regulation Evaluates threat and triggers response, violent outbursts, increased social intelligence Poor learning, behaviour, executive functioning Hippocampus volume reduced Corpus callosum volume reduced Cerebellar volume decreased Smaller prefrontal cortex Over-activity of amygdala (may be larger) and pre-frontal cortex Decreased EEG activity, esp L frontal hemisphere Decreased brain metabolism Malnutrition impairs global brain development So what we know about the brain structure and function as a result of neglect is that; The hippocampi are smaller The cerebellum is smaller so that means overall brain size is less The pre-frontal cortex is relatively smaller in size The amygdala, involved with fear and aggression is more responsive and in some cases larger – and we will talk more about what this means in terms of the response to fear and stress in a minute. There have also been EEG studies and PET studies (looking at glucose metabolism) that indicate decreased activity of the cerebral cortex esp the left side and decreased brain activity/metabolism. What these result in for the child is the behaviors that we see; problems in learning and memory, problems with executive functioning and planning of complex tasks, emotional dysregulation and violent aggressive outbursts.

35 The endocrine/neurohumeral system, what it does and what happens in the neglected or abused childThe second part of the neurobiology story is that of the stress system and its programming in early life in response to CAN.

36 Stress Stress = “stimulus or experience that produces a negative emotional reaction or affect including fear and a sense of loss of control” Physiological coping mechanism positive, tolerable, toxic Abused/neglected children - “whole existence in danger” Direct effect of violence - pain, fear Effect of observing IPV – fear Sexual abuse – fear, powerlessness, psychological and physical pain Neglect – fear of abandonment, discomfort, hunger Neglect is stressful but may not be traumatic Excess stress leads to inappropriate responsiveness of stress system Child maltreatment is stressful in a number of different ways. Stress response necessary for physiological and psychological coping.- for survival. Individual variations in response to stress – temperament. Prior experience is important in responses to stress. Maltreated children more responsive to stress. Positive v Tolerable v toxic stress Positive stress – kinder, new school etc Tolerable stress -physiological state that could potentially disrupt brain architecture but is buffered by supportive relationships that facilitate coping. Eg death of a loved one, natural disaster. Occurs within time-limited period and protective relationships help restore body. Supportive relationships in the context of child abuse could be the good enough parenting. Toxic stress - strong frequent and prolonged activation of stress response in absence of buffering effects of adult support. Toxic stress disrupts brain architecture and leads to stress response systems that are highly activated/responsive and remain so throughout life.

37 Stressor Stress response involves: Amygdala perceives stressActivates Hypothalamus Corticotrophin Releasing Hormone Anterior pituitary ACTH Adrenals Cortisol Stress response involves: Sympathetic nervous system (SAM) – immediate Adrenaline and noradrenaline Fight or flight Hypothalamic-pituitary axis (HPA) Cortisol Neuro-endocrine system Oxytocin Neurotransmitter system Immune system Dopamine Pre-frontal cortex Early life experiences mediate expression of Behavioural Emotional Autonomic Endocrine responses to stress Noradrenaline/adrenalin Simply, a healthy stress response includes sympathetic nervous system (SAM) - adrenaline and nor adrenaline (fight or flight) and the Hypothalamic Pituitary axis (cortisol). Helps the body to engage energy stores, alter blood flow and enhance certain memory and immune responses. In helathy stress responses the hormone levels return to normal once stress goes. Hypothalamus churns out CRH because the amgydala tells it that trouble is afoot. Trouble can be sensed through touch, vision, hearing, smell ….. The CRH acts on the pituitary and the pituitary releases ACTH and this goes to our adrenals. Adrenals are glands sitting on top of the kidneys. The kidneys produce adrenalin but also cortisol.. Cortisol goes back to the brain – negative feedback loop. Cortisol isn’t good for you in large amounts so if too much is released the brain (hippocampus) down-regulates the cortisol receptors. Stress is harmful because of the cortisol and adrenailn/nor adr.

38 Stress-induced remodeling of structure/connectivity inChanges associated with abuse and neglect – stress systems –SAM and HPA Stress-induced remodeling of structure/connectivity in Hippocampus Amygdala Pre-frontal cortex (control of feelings, emotions, attention, impulses ie executive functioning) Alters behaviour and physiological responses Anxiety Aggression Mental inflexibility Memory difficulties Other cognitive processes affected Maltreated children – cortisol abnormalities – reversed when placed in good foster care What we see is these stress-induced changes in the areas of the brain that we have previously identified. These children seem to have a persistently elevated response to stress. Maltreated children have different cortisol profiles from non-maltreated children; Severe neglect - Lower in the morning, flattened release during the day Severe EM – higher levels in morning

39 Stress hyporesponsive periodAfter early months the stress axis becomes hyporesponsive to protect developing brain from stress If early neglect/abuse this does not happen HPA axis continues to respond, cortisol produced, toxic effects to brain Child malRx is stressful. It leads to fear, pain, powerlessness. It leads to brain changes and changes in the hormone stress responses. There is one other important part – in normal children after the 1st few months of life the HPA axis becomes less sensitive. And for a few years it becomes hyporesponsive. This protects the developing brain from the toxic effects of stress. Brain doesn’t respond much to stress. If exposed to EA/neglect during this period then this doesn’t happen. The HPA axis continues to respond to stress and it’s adverse effects on the brain at critical periods of development.

40 The epigenetics story and the cycle of abuseAnd now we come to the final part of the story – that of epigenetics and the transmissibility of maltreating behaviours and their effects. Ill explain why there is a rat on this picture in a bit!

41 Genes determine POTENTIAL Environment determines HOW MUCH POTENTIAL IS REACHED -“nature v nurture” Abuse prevents children reaching their potential both through environmental deprivation and through environmentally induced epigenetic variation So we have talked about brain structure and we have talked about stress and the endocrine system and the effect of child maltreatment. On these systems. Finally we come to genetics and genetic vulnerability. Not all children are equally affected by maltreatment. Genetic endowment confers resilience. Depending on genetic endowment some children respond abuse in a way that is going to be harmful and some will be less affected. Most of the effects of maltreatment are not related to specific genes. What epigenetic refers to is the suggestion that there are effects which pass from generation to generation without actually effecting genetic make-up – ie rearing experiences that are transmissible.

42 Epigenetics alterations to gene expression without structural changes to DNA sequence molecular pathways regulating gene activity that have a critical role in brain development largely due to; methylation of DNA sequences Post-translational histone modifications Non-coding mRNA’s Methylation changes increase or decrease gene expression or result in gene silencing Epigenetic ‘signatures’ that can be inherited through mitosis The genes that a child inherits from its parents is known as the structural genome – the hardware of the computer if you like. Needs an operating system – and this is what is known as the epigenome. The epigenome determines which functions of the genome are turned on or turned off – regulate gene activity. These become chemical signatures that can be permanent or temporary and alter in response to experiences – toxins, stress. Epigenetics is the evolving field of study that focuses not on DNA sequences within the genome but on regulation of the activity of these genes. Epigenetic changes largely relate to changes in DNA methylation (to cytosines) but also to changes in the histone proteins and non-coding RNA molecules. These chemical changes can then be ‘inherited’ or transmitted through the generations.

43 Epigenetic changes associated with abuse and neglectEarly environment predicts later environment so development is adapted to that unique environment Quality of parent-child interaction induce epigenetic changes in developing brain Leads to variations in response to stress, cognition, sociability and reproductive behaviour Affects gene expression in brain cells, can be passed on Chemical changes initiated by life experiences Emotional/behavioural/psychological difficulties then become ‘inheritable’ Epigenetics is a form of developmental programming. Epigenetic changes refer to alterations to the gene expression but without alterations to the structural composition of the DNA nucleotide sequence. Chemical signatures attach themselves to genes and later the way that gene is expressed. These changes can affect the expression of genes in the brain cells, may be permanent or temporary and can be inherited by the persons offspring. The environment influences the chemical experiences, both positive and negative. Studies indicate that child maltreatment can cause epigenetic modifications.

44 Evidence? - look to the ratsRate natural tendency to lick/groom (LG) offspring varies Low LG’s – heightened stress-induced glucocorticoid levels, decreased memory/learning, reduced neural plasticity in offspring Low LG - decreased GR protein and mRNA in hippocampus as well as multiple other epigenetic changes in hippocampal tissue Can influence grooming patterns by manipulating environment Illustration of epigenetics at work in an experiments in rats. Now Long-Evans rat mothers are either high lickers and groomers of their offspring or low. High LG’s – responsive, nurturing parenting. Alters development of behavioural and HPA responses to stress, cortisol levels etc Offspring are more socially balanced, explorative and attempt to escape from threat (learned helplessness). Low LG have decreased hippocampal GR mRNA and protein expression.

45 Transmissibility and the ‘cycle of abuse’Maternal phenotypes transmitted to offspring who become low groomers Offspring of LG rats were LG’s Methylation changes in LG rats not present at birth – appeared in 1st week of life and persisted Transmissibility of behavioural phenotypes that can be altered by the environment later in life Evidence for impact of early life experiences adversity on offspring and grand-offspring Hope for early intervention strategies on cycle of abuse? In summary in relation to epigenetics it is safe to say that we have sufficient evidence that maternal phenotypes can be transmitted to offspring but that these phenotypes could be altered by cross-fostering and by the environment. Intersetingly the low LG offspring had increase sexual behaviour compared to the high LG offspring – not sure what to make of that! The methylation changes observed developed post-nataly ie directly in response to maternal care and environmental stimuli

46 What about in human infants?Difficulties in extrapolating Post-mortem studies Increased DNA methylation and decreased transcription of GR in hippocampus in abused suicide victims compared to non-abused suicide victims Salivary samples increased peripheral Nr3c1 (GR) DNA methylation in abused children (predicts stress reactivity) Biomarker for early life adversity Orphanage-reared children genome-wide hypermethylation These animal studies are difficult to replicate in humans for obvious reasons. However, PM studies and studies on peripheral DNA samples suggest similar changes . Developing field. May be biomarkers for early life adversity.

47 Cumulative harm – putting it all togetherSo we have some evidence that brain changes happen through mediating mechanisms of stress and deprivation or adverse experiences. That’s interesting, but so what? In what ways does it actually affect practice? Should it be affecting practice? What implications does all this have for intervention policies and strategies? Does this lend weight to Harry Harlow’s conclusions about adoption, security of placement, nurture over nature?

48 Extrapolating from biology to functioning – living with child abusePersistent fear response Hyper-arousal Increased internalizing symptoms Diminished executive functioning Working memory Inhibitory control Cognitive flexibility Delayed developmental milestones Weakened response to negative feedback Deprivation of experiences - neglect Lack of empathy Models of aggression Exposure to fear and trauma Pain Emotional insults Lack of affect regulation Unpredictability The meaning of living with child maltreatment. It includes these things…. . All these things are stressful. The changes we see in children are adaptive responses. Perfectly understandable adaptive responses.

49 Sophia’s story May Presented to the VFPMS for assessment of a likely scald burn to her shoulder – no explanation for the injury Found to have fractured front incisors and multiple splinters in her feet Acknowledgment to Dr Chloe Smith, VFPMS

50 Development at 2 years and 9 monthsNot formally assessed due to poor cooperation BUT reported as; Social passivity – unsure about social interactions Poor eye contact, responds to her name only 20% of the time Cannot/does not follow instructions Limited imaginative play Deficits in non-verbal communication Poor integration of verbal and non-verbal communication Does not point, limited non-verbal gestures Stereotyped and repetitive motor movements – hand flapping, rocking, picking of skin Possible echolalia No ritualised or repetitive behaviours Hyper-reactive to loud noises but no sensory issues Poor language development Aggression – punching people and animal cruelty

51 VFPMS observations Wary of strangersExtreme distress on physical contact, combatative Toe-walking, repetitive movements on the floor when approached – self soothing Rejected comfort, impaired emotional regulation Heightened sensitivity to noise and expressed fear - hypervigilant Protoimperative pointing (to request an object) Not dysmorphic

52 Sophia’s life Born to drug-addicted mother engaged in prostitutionFather incarcerated for violent crime, threats to kill, drug possession Exposed to repetitive family violence from young age Exposed to adult substance abuse Severely neglected, possible sexual abuse by step-father Physically abused – “tortured” with vacuum cleaner when naughty CP removed at age 2 years and placed with maternal GM (mental health, drug use, Hx abuse) Cycle of abuse continues Isolated at home, extreme distress on contact visits with step-father. Removed by Police – house “trashed”, domestic dispute, filthy environment, drug paraphernalia GM handcuffed and detained by 7 police officers

53 Emotional maltreatment NeglectWhat traumatic exposures has Sophia had? Physical abuse Possible sexual abuse Emotional maltreatment Neglect Environmental Physical – dirty, inadequate sleeping conditions, multiple splinters in feet, food issues Supervisory – drug affected carers Medical – failure to seek attention for significant burn, unimmunised Developmental – isolated, lacking in toys Emotional – lack of nurturance, affection, psychological care Isolating behaviours Terrorising behaviours Corrupting behaviours Unreliable and inconsistent parenting Denying emotional responsiveness

54 So what happened to Sophia?VFPMS - Plans for “re-unification” with biological father once released – not in best interests of Sophia! Behaviours typical of child living with Violence Chaos Threats to safety and wellbeing Hypervigilance, stranger wariness, poor attachment, distress, self-soothing, comfort rejection. Cumulative harm and severe neurodevelopmental trauma as a result of neglect and abuse Urgent need for stability of care Therapeutic foster placement

55 VFPMS review 3 months later – the arrow of timeCourt-ordered supervised access with step father Foster carers reported persistent rocking and fear of males, night-time wakening and fear, tantrums VFPMS Cooperated with examination fully with reassurance of carer No hypervigilance or sensitivity to noise Engaged with task with concentration No toe-walking, spoke full sentences Secure attachment to foster carer – imaginative play and invitations to play, sought comfort and reassurance No repetitive or self-soothing behaviours Brigance 85.5/100

56 “the exceptional transformation in Sophia’s behaviour and interactions supports the position that some of the harm caused by her neglect is reversible provided that she lives in a secure and stable environment, has the opportunity to further develop secure attachments and is not subject to emotionally traumatic experiences or circumstances”

57 The assessment pathwayObservations and information gathering Organise into tiers of concern and fill in gaps Describe tier 2 interactions and persistence Which tier 3 concerns are attributable to neglect/EA Estimate severity Interventions (addressing tier 0 and tier 1) Tier 2 caregiver child interactions Tier 3 child’s functioning Tier 0 and 1 social, environmental and caregiver RF’s

58 The arrow of time Chronic and insidious Follow-up paramountDemonstrate improvement/deterioration in domains of impairment and in parent-child interactions Be explicit

59 N.E.G.L.E.C.T.I.N.G – an acronymNurture Emotional needs Growth and nutrition Learning and development Environment at home Clothing Teeth Immunisations, infections, infestations Normal social activity General health Within the VFPMS myself and Anne have put together an acronym to serve as a aide-memoir or framework for assessing vulnerable children. This is the NEGLECTING acronym presented here with each letter representing an area of interest if you like. \We can see this in its full glory….

60 VFPMS website under Guidelines

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62 Conclusions Thorough assessment Identify types of neglectStatements regarding severity/thresholds Identify harms or likely harms Make clear recommendations Follow up BE EXPLICIT Don’t be afraid Our aim is to change the trajectory of this child’s life I’ll finish now with this summary slide – that what we know is that there are adverse effects on a child’s brain structure and functioning and on their responses to stress through adverse early life experiences. That these are important and may be persistent adverse effects but that they can be somewhat remediated by improvements in environment and caregiving behaviours. This should have implications for intervention, for understanding the nature and effect of cumulative harm, for supporting a policy of stable placement for infants and young children and for ongoing parallel parenting education and support. Thank you.

63 References & resourcesUnderstanding the effects of maltreatment on brain development; Child Welfare Information Gateway April 2015 The effects of child maltreatment on the developing brain; Glaser D; Medico-legal journal 2014 Vol 82 (3) The neuroendocrinological sequelae of stress during brain development: the impact of child abuse and neglect; Panzer ; African Journal of psychiatry Feb 2008 Reversing the real brain drain Early years study April 1999 The pervasive and persistent neurobiological and clinical aftermath of child abuse and neglect; Nemeroff et al; J Clin Psychiatry 2013 Epigenetic programming by maternal behaviour; Weaver et al; Nat Neuroscience 2004 Early-life experiences, epigenetics and the developing brain; Kundakovic et al; Neuropsychopharmacology 2015 Epigenetic mechanisms for the early environmental regulation of hippocampal glucocorticoid receptor gene expression in rodents and humans; Zhang et al; Neuropsychopharmacology 2013