Audio transcript (edited)

MS DAVIS

Hello everyone and welcome to today's webinar, Developmental differences in children who have experienced adversity: emerging evidence and implications for practice.

My name is Elise Davis and I am Manager of Workforce Development and Evaluation here at the Australian Institute of Family Studies.

Today's webinar presentation will outline emerging evidence on the impact of early adversity on children's development and implications for practice. In addition to this presentation, a series of practice guides focussed on developmental differences in children who have experienced adversity has also been developed and will be released this month. Please subscribe to the CFCA newsletter to receive notification once they're available.

Now, before I introduce our presenter, I'd like to acknowledge the traditional custodians of the land on which we are meeting. In Melbourne, the traditional custodians are the Wurundjeri people of the Kulin nation. I pay my respects to their elders past and present and to the elders from other communities who may be participating today.

And, firstly, just some housekeeping details. So, one of the core functions of the CFCA information exchange is to share knowledge, so I'd like to invite everyone to submit their questions via the chat box at any time during the webinar. We will respond to your questions at the end of the presentation. We'd also like you to continue the conversation we begin here today, so to facilitate this we've set up a forum on our website where you can discuss the ideas and issues raised, submit additional questions for our presenter and access related resources. We will send you a link to the forum at the end of today's presentation. As you leave the webinar, there'll be a short survey. It'll open in a new window and we would really appreciate your feedback.

Please remember this webinar is being recorded and the audio transcripts and slides will be made available on our website and YouTube channel soon. And it's now my pleasure to introduce today's presenter, Dr Sara McLean. 

Sara is a consultant psychologist and Adjunct Fellow at the Australian Centre for Child Protection. She has worked in the area of child and adolescent mental health since 1997 and has a particular interest in developing effective supports for children in care. Sara has expertise on the psychological issues associated with fetal alcohol [spectrum] disorder and the mental and behavioural needs of children living in foster and residential care. Sara was the recipient of the ACU Linacre Fellowship at Oxford University in recognition of her work supporting children in care.  She consults to government and non-government agencies on children with complex support needs, including high stakes behaviour.

Please join me in giving Sara a very warm, virtual welcome. 

DR MCLEAN

Thank you very much, Elise.  And thank you to everyone who's taken the time to take part in this webinar today. I know that everyone's very busy, so I do appreciate that. And I'd just like to acknowledge that there's a lot of material that I'm going to cover today but you're a large and diverse audience so I'd like to acknowledge that I possibly won't meet everyone's learning needs today, so please do feel free to post questions or to email me directly after this webinar so I can make sure that you get your burning issues addressed. That would be great.  

Okay, so as Elise has mentioned I'm a psychologist by background, my experience is in child and adolescent mental health where I was the senior clinical psychologist in a few tertiary therapeutic day programs for young people with serious and significant behaviour and mental health issues. I've also been involved in research and my research is very much applied and addressing the issues involved in supporting children with complex and challenging behavioural mental issues in the out-of-home care space. So, focussed on foster care, residential care and, as Elise mentioned, a very strong focus on raising awareness about the impact of prenatal events on children's lives and in particular fetal alcohol spectrum disorder.

My current focus is on research translation and hence the reason for this webinar today to bring emerging research knowledge into practice and to generate a bit of discussion and practice around what that might mean for supporting children and families.  

In this presentation, I really just want to do two things, and one is to highlight, as Elise has done that there are some – a series of four practitioner guides that are coming out soon. It sounds like they might be out later on this month and they form the basis of the second half of this presentation and they're about the emerging neuropsychological – sorry, neurocognitive research around real time brain reactions to social and emotional stimuli in children who've experienced early adversity and the second part of the – the other thing that I would like to achieve today is to really give you a broad overview of the program of work that I've been undertaking for the last little while. In which I've tried to focus on common developmental trends or developmental needs amongst children who've experienced a range of early life adversities and also amongst children who have clinical disorders of childhood that are associated with behavioural and emotional and mental health issues.

So, I've called this work – the issues that I've uncovered – I've called them developmental differences, and I really like this term, because obviously developmental tells us that these differences arise in the context of a child's developmental experiences.  Which also includes their prenatal experiences and differences in recognition that children who've experienced significant early life adversity have reasonably predictable patterns of neurodiversity.  So, differences in the way that they process and interact with the world.  

So differences, not better or worse, just sort of difference. So, recognising that many children who have experienced early adversity will have developmental differences and then beginning the conversation about what we could do to offer more effective services for these young people. As I said I'd like to – one of the goals for today is to just give you an overview of the kind of work that I've been doing, in case it's of interest. A lot of my work has been involved in a program of research, but then research into practice, regarding the needs of children with developmental difference and particularly in out-of-home care. 

I'd really like to highlight that this isn't just my idea. This is consistent with international trends in research and research translation that are beginning to step outside of diagnostic labels and diagnostic approaches and really focus on addressing the underlying difficulties, or differences, in the key domains of functioning that affect children's behaviour, learning and social experiences. And if you'd like to see around some of the research programs that have been done in this space, I would refer you to the National Institute of Mental Health in the USA. So, this is a growing trend in preventative mental health internationally. And this is really just to say that the approach that I have taken has been very much around integrating diverse bodies of knowledge to identify common elements.  And here's a nice little schematic that sort of simplifies the body of work that I've been doing.

So, firstly, in the area of clinical and forensic psychology. I've really drawn on the evidence base regarding childhood disorders that are known to be associated with challenging and complex behaviours, particularly those that affect placement stability and I've also drawn on the childhood disability or diagnostic literature to draw on the information about what is known about common clinical disorders of childhood that are also common in children in out-of-home care. So, for example, conduct disorder which we would expect about 60 per cent of children in out-of-home care would attract a diagnosis of conduct disorder, anxiety around 11 per cent, depression around 17 per cent, I believe, and so on. So, I've really asked what are the common functional difficulties experienced by this group of children?

Secondly, I've drawn on the literature that is theoretical but also research literature in relation to the effect of early childhood events.  So, theories of complex trauma, theories of attachment and the evidence base around early traumatic experiences and experiences of neglect, but also the larger and really much more robust evidence base around the impact of prenatal alcohol and other substance uses which, of course, are significant issues for our children in the care system or most of our vulnerable children. So, for example, with fetal alcohol spectrum disorder we estimate that across all settings – out of home care settings and internationally we conservatively estimate that around 17 per cent of our kids are – would attract a diagnosis of fetal alcohol spectrum disorder.  

Finally, drawing down on the emerging evidence base regarding structural and functional difficulties that arise from the body of neurocognitive research and I'll talk a little bit more about that when we come to the practitioner resources and really with an aim to highlight common themes and common development issues across all these bodies of work.  

Just from a philosophical point of view, I just want to say that often when we start talking about neuropsychology we start to – people start to think that it's a very reductionistic approach. My view is that it's just one piece of the evidence and this kind of approach in focussing on developmental differences is not supposed to be a substitute for relationship-based interventions, attachment interventions that emphasise the significance of safe and nurturing relationships or trauma-informed principles. My argument would be that these are essential to our interventions in the child welfare space, but I would argue they're necessary but maybe not sufficient for many children in out-of-home care.  

I believe that the approach to addressing and annulling difficulties, or differences, better captures a broad range of complex influences that can affect children's lives. I think that we need to cast a wider net than we do when we focus on attachment or trauma.  And, arguably, I would say that – and certainly this is the trend in international literature – that this kind of approach might be more likely to result in targeted, as opposed to broad brush, interventions.  And this is really not a deficit model or a deficit way of thinking per se. I like to think of it as an ecological kind of approach. We can think of children's difficulties that arise in the context of early adversity in terms of differences in the way that they process the social, informational and cognitive sensory information in the world.  So, primary differences in the way that they experience the world that become, can become or have the potential to become problematic over time. Now, I think the fetal alcohol spectrum disorder literature addresses this issue very nicely when they make a distinction between primary and secondary difficulties.

So, here's my attempt at a schematic to sort of explain this. So we have a child with developmental differences who's developing over time. Surrounding the child with developmental differences is their care-giving environment, which can either support or hinder their development, and so we believe now that the kind of care-giving environment that supports a child with developmental difference is a highly structured and predictable environment in which caregivers are able to change their expectations to meet the needs of the child; to meet a child at their developmental level; that they're able to scaffold and simplify a child's world by using visual supports, simplifying their language and so on. And we'll talk a little bit more about that a little bit later. And, finally, and particularly as a child gets older, we need to be asking how they experience the services and systems that we provide for them, because these social interactions can either magnify their difficulties or support the child with developmental difference.  What coping strategies are we teaching them and how are we interacting with them as service providers?

Before I move on to talk about developmental differences, I just wanted to touch briefly to let you know some of the work that I've been doing and some of the work that I'm hoping to do in the near future.  Firstly, and probably most importantly for those of you who are working with foster carers, I've developed a series of free resources for foster parents, which is part of – began as part of a project supported by the generous support of the Eureka Benevolent Foundation and these were co-developed in partnership with foster carers, so I'm appreciative of the time and expertise that they offered to the project. 

I've developed a basic website, which is the Fostering Difference website, where you can see the logo down there.  And you may want to have a look at that and download some resources that are targeted at foster parents, and we're looking to upgrade and improve that website over the next few months. I've also written a book for foster parents that should be coming out shortly that outlines the differences in care-giving that are required for children with developmental differences.

I've been fortunately enough to contribute to policy and therapeutic frameworks around residential care, foster care and secure care and I'm interested in developing some training materials in that space.  And shortly there'll – I think, in the next month or so –there'll also be an update of the therapeutic residential care paper coming out through the CFCA portal or website.

I've also started beginning putting together some resources for child protection workers and foster care support workers and currently writing a chapter for a book around the educational needs of children with developmental differences.  So just to give you a sense of the kind of research-to-practice translation activities that I've been involved in.  If you'd like to learn about those, the Fostering Difference website is a good place to start for foster parents but you can also get updates via the Facebook of Fostering Difference once that becomes active. So I'd encourage you to visit there.  

Alright, so what are the main developmental differences experienced by children who've experienced early adversity?  And much of this information is available on either the Fostering Difference website or some of the CFCA papers that I've done in the past, so you can probably search on the CFCA website and find some of these. So the first area of developmental difference relates to children's sleep and circadian rhythms. And this is an area of difference that people don't often focus on and when we do we're kind of aware that a traumatised child might have nightmares or they might have difficulty with sleep onset insomnia, but what we don't appreciate often is that children who've experienced early adversity can have a lot more free floating circadian rhythms and have a lot more difficulty than we do in anchoring their sleep-wake cycle to the daily rhythms of society. And for foster parents who are raising children with fetal alcohol spectrum disorder in particular will talk about the profound sleep disturbances that happen as a result of this pervasive developmental issue.

So, children with fetal alcohol spectrum disorder will often sleep for, you know, two or three hours, four hours, and then they'll be awake for a long time. So, a profoundly disrupted and exhausting sleep patterns for carers. 

 Secondly, children can have difficulty in regulating their sensory world and that means they could be over-responsive or under-responsive to the sensory world, but what it really means for children is that the sensory world can affect their level of alertness, their level of arousal, so they become sleepy or they become hyperactive and it becomes much more difficult for them to engage with a world and benefit from learning – benefit in a learning environment.  And just to let you know that at the Fostering Difference website I've got a resource on sensory regulation that's developed specifically for foster parents. So, you're welcome to visit that and download that resource.  

The other area of developmental difference that I'd like to highlight is profound differences in language, in comprehension and communicating. Children who've experienced early adversity of all sorts will have – are likely to have – difficulties in receptive and expressive language. So they can have delayed receptive and expressive language, but also disordered language. And a very common form of language disorder is pragmatic language disorder, which can be very difficult to detect and sometimes masks the level of difficulty that children are having.  So pragmatic language disorder relates to difficulty with the social use of language.  So difficulty in turn taking, taking language very literally, trouble with abstract concepts like goal setting and reflecting on behaviour and so on.  

And particularly when it comes to asking children to reflect on their behaviour, language issues have a profound impact on children's ability to engage in reflective – to engage in reflection about what they might have done wrong and what's contributed to their behaviour problems, and that's something that we often ask them to do.  So, on the Fostering Difference website, I've got a resource that explains language disorders in relatively simple language and that's designed for foster parents, but again it might be something that other workers might find useful as well.

Okay, so other developmental differences that have come out of this research and research integration are difficulties in emotional regulation. I think people are much more familiar with the concept of difficulties in emotional regulation amongst children who have experience early adversity.  We know that emotion regulation difficulties are common amongst children who attract a diagnosis of conduct disorder, fetal alcohol spectrum disorder, anxiety disorder, oppositional defiant disorder and so on.  All the disorders really.  So difficulty with emotional regulation is a big issue and there is a resource about emotional regulation on the Fostering Difference website.

I'd just like to flag, in case I forget to do that later, that we often focus on children who have poor emotional regulation as in they're very emotionally expressive and overly dramatic, overly attention seeking and some of the labels that get attached to their emotional regulation difficulties. But, equally, children can have emotional regulation difficulties in the sense that they have trouble even expressing emotions or recognising emotions, so they're very emotionally restricted. So you can have the two extremes and we tend to focus more on the in-your-face kind of kids, rather than the more introverted, internalising children.

Okay, difficulty with executive control. So, executive control is like the air traffic controller of our brain. Executive control is central to our ability to set goals and achieve goals. It's central to our ability to think flexibly, to manage transitions and adapt our behaviour from situation to situation. Difficulties with executive control are very well documented in the clinical literature around autism spectrum disorder, conduct disorder, anxiety and trauma. And, once again, there is a resource developed for foster parents that you can refer to, to help explain in simple language what executive functioning and executive control is all about. 

And, finally, there is what the cognitive behavioural therapists will call a hostile attribution bias in many children who have experienced early adversity. So, what that means is they have a heightened perception of threat in social situations or in response to social interaction, but also that they find – tend to find – social interaction less rewarding, and we'll talk about that in a minute when we come to the neurocognitive literature.

So, this concept is really known in cognitive behavioural therapy, where these kind of issues are explicitly addressed in kind of approaches that we use for anger management, managing of anxiety and depression as well. So, there's some good cognitive behavioural strategies that we can draw on. And I think I've just put that paper there about the effect of trauma on brain development just for those of you who may not be aware of the resource that I wrote towards the end of 2016 that really provides a general overview of the current state of evidence and theory in relation to brain development and trauma that I thought you might find interesting or useful.  

And so all of these difficulties on this slide are really the same difficulties that were found in the neurocognitive research and so I want to move on to talk about that, because they are the impetus – that research is the impetus or the stimulus for developing those four practitioner resources that will be coming out later this month.  

Yes, and this is really just to say the remainder of this webinar is really drawing on the program of work developed by Eamon McCrory and colleagues at University College London, which has really done a lot of work in terms of integrating neuropsychology, the structural neurobiology and the functional neurocognitive research and what that might mean for children who have experienced early adversity.  

So, as I said, the idea for the resources came from that work, which was published late in 2017. So I was keen to get that research out to practitioners as soon as possible. The only concern that I have around this research – or it's not a concern but, really, we need to be aware – that neuropsychologists and neurocognitive researchers tend to use pretty set paradigms to explore children's functioning. They tend to explore information processing and the processing of social stimuli like angry faces and those sorts of things in fairly experimental, controlled conditions. They don't explore things like sensory regulation or sleep disturbances as such, so they find what they go to look for in other words.

But anyway, notwithstanding that sort of concern about the literature, this program of neurocognitive research which looked at the real time reactions of children's brains to social stimuli, such as angry faces – or threatening stimuli such as angry faces – they found these four areas of developmental difference similar to what we found in our literature reviews. As neuropsychologists they talk about these in terms of being latent vulnerabilities; being underlying processing differences that convey a vulnerability in the child for the development of mental health issues later in life or perhaps in response to a stressful trigger later on in their life.

And the four areas of developmental difference that come out of this neurocognitive program of work are two involving social information processing and that is the way that social or neutral stimuli – neutral social stimuli – are experienced as threatening.  The way that neutral social stimuli are not experienced as rewarding and the way that emotions are processed within the child's brain and also the way that executive tasks are processed in the child's brain.  These differences in the neurocognitive research are really capturing differences at the neural level. That's different from the structural research, which looks at shapes of different areas of the brains or the size and the functioning of different areas of the brain.  This is around capturing the reactions at a neural level in real time as children process different stimuli in the world.  

So those are the four areas that form the basis of the practitioner resources that'll be coming out later in this month.  Why did I think this was important stuff to highlight to practitioners? Well, I think, because it really encourages us to take a preventative approach to our work and I know that we try to do that, but it really highlights some of the underlying difficulties that can become mental health concerns later on down the path without sufficient support. So it challenges us to think a little bit differently about what we can do to prevent the development of mental health issues for children.

Significantly, this program of neurocognitive research found that these developmental differences in social information processing, emotional regulation and executive control existed in children even who appeared to be on the surface perfectly healthy, who had not yet experienced any mental health issues. So they exist whether or not there are mental health issues or behavioural issues in place. They occur in a way, in a level, in characteristics that are comparable to adults who have mental health concerns and psychiatric concerns.  

What I really like about this body of work is that they view these developmental differences as entirely appropriate and adaptive brain responses to children's early care-giving environment, but acknowledge – much like the ecological model – that they represent a difference that can convey vulnerability later in life depending on what else happens to a child.  

The other significant thing is that they view these developmental differences as possibly rendering children less able to benefit from, and less able to take part in, the kind of corrective experiences that we would like them to have. So, for argument's sake, you know, to place a child into a foster home – a child who's experienced early adversity – they may still, even though they are in a nurturing and supportive environment, …their underlying developmental differences may minimise their opportunities to benefit from corrective social experiences.  And it really highlights – that series of papers – really highlight the need for preventative interventions and mental health first aid or stress inoculation approaches for children and families who are experiencing adversity and also the need for targeted interventions that specifically address the underlying developmental differences in social information processing, executive functioning and emotional regulation.

Okay, so now I'd like to move on to actually what these papers demonstrated in terms of the developmental differences and I'll deal with threat processing and reward processing together as two of the ways that children's experience of the social world is altered as a result of their early life adversity. So, two ways that social information processing is altered.  

First, this body of research on real time responses to stimuli showed us that children who've experienced adversity have an altered, and often enhanced, reactivity to stimuli that can be seen as potentially threatening. So in this kind of scenarios it would be a picture of an angry face. So, they are more reactive to those kinds of stimuli. We know this is significant because adults who have significant mental health issues, there's also been this kind of documented altered threat response in those psychiatric populations as well. So we know that there's a link between these difficulties and the development of mental health issues.  

What the neurocognitive research tells us is that – and this is very good longitudinal research – is that, if you take a child and you measure their threat reactivity at time one, prior to any major stressful life event that we know of, if they have high threat reactivity at that time and then they've been subsequently exposed to a stressor or removal or a placement in a home or some sort of stress like that, then their threat reactivity at time one predicts the development of psychopathology in those children later on in their lives. So, we know that it conveys a vulnerability for mental health issues over time. We know that this difference in threat reactivity can be detected as early as 15 months of age so it can come about very early in a child's life.  

For children who've experienced institutional neglect or neglect in the context of institutional upbringing, they also have significantly more subcortical sort of real estate invested in the detection of threat cues and this happens in a dose dependant way.  So what that means is the longer the period of emotional neglect in an orphanage, the higher the threat response. And also in child welfare or social service populations these researchers have also found that compared to match controls there is a dose dependant increase in threat reactivity, which is proportional to the level of the abuse and the complexity of the abuse that they've experienced. So all that is very consistent with the theory of complex trauma, but it's more complicated than that because there is also emerging research that children can engage in enhanced vigilance but also enhanced avoidance. So, for some children, there's actually a lower reaction to threat, but we don't quite understand the reason for that. But it's interesting to note that heightened vigilance – seeing threat where there is no threat and engaging in behavioural avoidance – are two core characteristics of anxiety disorder.  So we think that children with this altered reactivity to threat can be more vulnerable to the development of anxiety.

Okay, moving on to children's neural response to rewarding stimuli.  What we know is that – or there are many reward systems in the brain – the one that they're mostly focussed on in this body of research is the reward systems that drive our anticipation of impending reward which is driven by the dopaminergic system.  So really the anticipation that this stimulus or this interaction is going to be rewarding from a social perspective. And we know that, you know, children who have a blunted or a diminished reaction in anticipation of social rewards, they are more vulnerable to the development of mental health concerns over time.  And some of this neurocognitive research has shown that even a large samples of 1,500 community – teenagers living in the community rather – who are ostensibly healthy when for those children or adolescents who have been found to have this blunted or diminished response at a brain level in the anticipation of reward, those children are more at risk for the later development of depression even when they were not currently experiencing mental health issues, so that's very important to emphasise. And McCrory and colleagues have also found this blunted anticipation of social reward response in their maltreatment research as well.

So all of that is very deficit focussed and negative, and that's pretty well the nature – can be the nature – of this work, but it's also significant to notice where research has looked at children who have a heightened anticipation of reward response and this research demonstrates to us that this can actually be a protective factor.  That for these children are at less risk of developing depression over time. So that gives us great hope that intervening in this space will actually offer a protection to children. And Eamon McCrory makes a point that these differences in the way that children process the social world are really about perfectly adaptive survival mechanisms that mirror the child's – perfectly match the child's – early care-giving environment. But, from our perspective as supporters of children and families, what these differences in social processing may convey is a really perfect storm of risk factors.  McCrory makes the note that these things often co-exist and so these difficulties, or these differences, may place a child in increased risk for anxiety and depression, starting off or reinforcing spiral in which a child might have less desire to explore the world because the world's a scary place and they also might have less motivation to explore. And, therefore, they have less opportunity to have corrective experiences because the social world is not – they don't anticipate any joy coming from the social world.

Okay, so what does this all mean for what we do with families?  This is really uncharted territory.  I think the first thing to really put in the forefront of our minds is the fact that children's experience of social interaction is different. It can be fundamentally different from what our experience is.  And, I think it's also important to help them reframe this difference in terms of a positive and clever survival strategy.

Like the public health approach or a public health concept, I really like the idea of stress inoculation training. That is, using positive evidence-based programs and activities taken from positive psychology and mindfulness in particular to support a positive outlook, staying focussed on the present, noticing the positives and developing gratitude. There's also a need to take a graduated approach to children's social experiences.  We can think of it in cognitive behavioural terms as an exposure hierarchy.  So we really want to gradually introduce them to social situations and give them more and more opportunities to master and experience positive interactions. And, finally, there's a very strong evidence base around cognitive behavioural approaches to supporting children to identify, highlight and challenge some of the automatic assumptions that underpin their beliefs around social interaction and the social world. 

Okay, so moving on to another major area of difference that was identified in the neurocognitive research is that around emotional regulation.  We've already touched on this, but this speaks to more the neurocognitive research around that. And, basically, emotional regulation is implicated in many adult psychiatric diagnoses and so we know that in some way or another it's often related to poor mental health outcomes in children.  When McCrory's reviews have looked at the relationship between emotional regulation and maltreatment they have cited studies that have looked at poor emotional regulation at age seven.  By the age of seven as being predictive for later poor mental health outcomes, particularly of an internalising, anxiety and depression form.  

Pop that up there.  So the majority of the research shows that emotional regulation is much for effortful. It requires much more cognitive resources for a child to engage in emotional regulation if that child has a history of early life diversity – early life adversity, sorry. But there are some interesting patterns emerging in that some children actually – particularly in relation to social stimuli that are involved in rejection, so threats of a rejection – they actually engage more in avoidance than trying to control and regulate their world.

Okay, so what can we do about it?  Really, we don't know much about this, but what we think works well is taking them right back to their developmental level, building their emotional language that they need to support their emotional development. They need to have the language first before they can actually engage in conversation and reflective practice around their emotions. We need to support them to understand how their emotions are reflected in their own bodies in unique ways and particularly children who are highly somatic.

We need to support them – children and families – to devise and rehearse ahead of time ways to safely express their emotions and to develop cognitive coping and active coping skills. And because children's social and emotional development happens in a social context, often they have the message that they need to deny or distort the emotions; that some emotions aren't safe to express, or they haven't been safe to express in the past, so we really need to ensure that we are role modelling the way to express emotions or that all emotions are acceptable and exposing them to positive role models in that regard.

Okay and the final area of neurocognitive difference that was identified in these extensive reviews relates to this issue of executive control and executive functioning. Executive functioning really is a whole range of interrelated brain functions that go together to make-up our ability to think on our feet, to benefit from feedback, to predict the outcomes of our actions and to adapt our behaviour from situation to situation, task to task and conversation to conversation.  It's been likened to the air traffic controller of the brain. It's significant because executive functioning difficulties are intimately involved with many psychiatric diagnosis, especially of those of the OCD sort of cognitive rumination type of difficulties.  

So what does the neurocognitive research show us?  It shows us that, in children who've been institutionalised or experienced institutional neglect – these are the orphanage type studies – these children show greater activation in areas of the brain that are involved in this effortful control of executive functioning.  Particularly when it comes to shifting from task to task, which many foster parents know very well.  So that transitioning from task to task and that cognitive flexibility and also keeping track of their performance and monitoring their own performance.  

Similarly, with samples of adolescents who've experienced abuse, there's also this increased activity in the areas of the brain that are involved in the effortful control of executive functioning. In the case of adolescents, this focuses more on inhibiting their behavioural responses and keeping track of their behaviour. But the last thing I'd like to say about that is that in longitudinal work though, in terms of the outcomes for children, this work has also highlighted the significant contribution of a children's overall cognitive ability before stressful or traumatic events and general sort of specific disadvantage factors that are related to their socioeconomic background. For me that highlights the potential of, or the significance of, intellect or IQ but also prenatal alcohol exposure.

And so what can we do about this? For children, the hallmark of poor executive functioning is difficulty with transitions and difficulty in thinking flexibly. We can help children by providing a structured and predictable environment. We like to support carers to adjust their expectations of children, to simplify their interactions and simplify their environment by providing visual supports. And transitions of all types need to be supported by a structured process and warnings and there are visual cues that you can use to support transitions in children with poor executive control.

And I just want to say that these strategies are all outlined in the Fostering Difference website, but also will be outlined in the CFCA resources once they come out at the end of the month.  And we also need to scaffold them and teach them the missing skills. There are very good strategies for supporting kids to plan, to monitor their own activities, to build their working memory during – you know, using games or phone apps and to – we need to support them with their flexibility in their thinking, being able to adapt from situation to situation. And we do that by highlighting what's same and what's different about upcoming events. So those strategies are all outlined in the resources that I've referred to.

Okay, so just to summarise, you know, how can we support caregivers and how can we service providers make life better or easier for children with developmental difference?  The first thing is really to my mind, really keep in the forefront of our minds, that once we place a child in physical safety it is not the same their experience of psychological safety.  They’re likely not to find social interaction rewarding and that we need to support children and families in vulnerability, who are experiencing vulnerability and early life adversity, in the evidence based CBT positive psychology and mindfulness strategies for all families irrespective of whether or not they're currently showing any mental health and behavioural issues.  For children who've experienced early life adversity it may be about going back to the basics around their emotional vocabulary, their permission to express different emotions, encouraging emotional expression in children who are avoidant and encouraging coping strategies in those who are overreactive. And particularly the case for children who also have language issues, which is extremely common in out-of-home care as well. And we also need to build into our parenting programs the capacity to build their executive functioning skills by providing a supportive environment, a structured environment, and helping them to build the necessary skills. 

And I'll just flick to the end here.  And I think these strategies are useful for all children who've experienced adversity, not just children in care and not just those that are showing current mental health issues.  So I just want to finish there with the opportunity to consider a couple of questions about you know, how can we support parents and caregivers and how can we, as service systems and practitioners,  how can we make our services and our interventions more useful for children who are likely to be living with developmental difference? Thank you for your time.

WEBINAR CONCLUDED

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Slide outline

1. Early Adversity and Developmental Difference

Dr Sara McLean

BSc., Hons., M.Clin Psych., PhD.

Consultant Psychologist, Child Protection.

2. Early Adversity and Developmental Difference

• Introducing a program of ‘research to practice’ regarding Developmental Difference in out of home care.
• Consistent with international trend towards trans-diagnostic approaches and focus on domains of functioning.
• Integrating bodies of work from clinical and forensic Psychology; neuropsychology and neuro-cognitive research; and literature on impact of prenatal and early childhood events.

3. Diagram: Three areas of knowledge that inform understandings of development difference

Diagram shows three circles that depict three areas of knowledge that inform understandings of development difference.

1. Clinical and forensic psychology;
2. Prenatal and early childhood event; and
3. Neuro-psychology and neuroscience-cognitive research.

4. Early Adversity and Developmental Difference

• This approach is not a substitute for ‘attachment based’ or ‘trauma-informed’ approaches.
• Better captures the broad range of influences on children’s development in vulnerable populations; especially young people in care.
• May be likely to result in targeted interventions, tailored to underlying needs.
• Difficulties can be viewed in terms of chronic mis-match between young person’s experience and social systems.

5. Diagram: Primary and secondary difficulties experienced by a child with developmental difference.

Diagram aims to illustrate primary and secondary difficulties experienced by a child with developmental difference.

It shows a child with developmental differences developing over time within two concentric circles depicting two types of environments, which can either support or hinder their development:

1. The inner circle represents the child's caregiving environment; and
2. The outer circle depicts the society, services and systems that surround the child.

6. Diagram: Policy and therapeutic frameworks

Diagram shows two concentric circles. The outer circles represents policy and therapeutic frameworks and the inner circle represents practice resources and curriculum that aim to support children with development differences. In the centre of the circles is a child with developmental differences. Distributed along the border of the two concentric circles are four separate circles representing different professionals that work with children with developmental differences:

1. Parents, carers and foster carers;
2. Residential care and secure care workers;
3. Child protection workers; and
4. Legal and education professionals.

7. Developmental differences

• Disrupted sleep and circadian rhythms
• Difficulty in regulating the sensory world
• Difficulty in understanding and communicating

8. Developmental Differences

• Difficulty with emotional regulation
• Difficulty with executive control; memory & organisation
• Differences (bias) in social information processing:
  • Threat and reward processing

9. Diagram: Neuro-cognitive vulnerabilities and developmental pathways of young people who have experienced early adversity.

• This series of four practice papers drawing on McCrory et al (2017) program of literature reviews and research on the neuro-cognitive vulnerabilities and developmental pathways of young people who have experienced early adversity.
• Diagram shows three circles that depict three areas of knowledge that inform understandings of development difference. 1. Clinical and forensic psychology; 2. Prenatal and early childhood event; and 3. Neuro-psychology and neuroscience-cognitive research. The last circle depicting neuro-psychology and neuroscience-cognitive research is highlighted

10. Early Adversity and Developmental Difference

• Eamon McCrory and colleagues have a program of research integrating neural, neuropsychological, structural and functional brain imaging research (Traditional areas of neurocognitive functioning).
• 4 areas of developmental difference; which they describe as latent vulnerabilities, as they convey developmental risk for socio-emotional and mental health difficulties in later life.
• Developmental differences in:
  • Threat processing
  • Reward processing
  • Emotional control
  • Executive control

11. Developmental Difference

• Developmental Differences in information processing that:
  • Exist without overt mental health symptoms.
  • Similar to adults with mental health concerns.
  • Originally adaptive; but may convey vulnerability later in life.
  • May reduce potential for corrective experiences and social exploration, reduce motivation and other learning opportunities.
  • Need for preventative interventions- even in the absence of overt symptoms- specifically addressing developmental differences in social and information processing and regulation.

11. Developmental Difference: Threat & Reward Processing

• Altered reactivity to ‘threat’: Hyper- but also hypo-reactivity. Both vigilance and avoidance; characteristic of anxiety disorders. Generally consistent with theory of complex trauma.
• Blunted response to ‘reward’: areas of the brain associated with resilience. Calibration’ of brain in response to inconsistent and scarce reward contingencies in early environment (McCrory et al., 2017).
• ‘Perfect Storm’ of risk: anxiety, depression- ‘reinforcing’ spiral of reduced exploration and mastery.

13. Implications: Supporting children and families

• Implications for practice:
  • Strengths-based narrative.
  • ‘Stress Inoculation’: Distress tolerance, active coping skills & attention ‘training’/planning (positive psychology), mindfulness.
  • Alternative experiences: opportunity for mastery.
  • Cognitive coaching techniques: thought detectives.

14. Developmental Difference: Emotional Regulation

• Emotional regulation:-capacity to produce changes in activated emotions. Involves attention modulation; suppression; and cognitive re-appraisal.
• Greater effortful control required. Structural differences; connectivity and activity findings mixed; suggesting pattern of management by avoidance or effortful control.

15. Implications: Building emotional regulation skills

• Implications for practice:
  • Emotional vocabulary
  • Body-mind connection
  • Safe emotional expression and regulation; coping skills
  • Positive role models

16. Developmental Difference: Executive Functioning

• Executive control: planning, flexible thinking, working memory and predicting outcomes. Updating (working memory= control of sustained attention); inhibiting (controlling behaviour inconsistent with goal) and task shifting (switching back and forth between tasks, mental states or concepts). Air traffic controller.
• Differences in functional imagery activity in those exposed to maltreatment. Likely contribution of pre-existing cognitive impairment and socio-economic factors.

17. Implications: Building executive control

• Implications for practice:
  • Structure and predictability
  • Simplify and support transitions
  • Scaffolding strategies and skills
• Getting started and keeping on track
• Flexible thinking

18. Implications for Practice

• Physical safety does not equate to experience of safety; and social interaction may not be rewarding. Stress inoculation important.
• Emotions may be diminished, delayed or distorted and foundations of emotional literacy need to be taught.
• Building executive control (organisation, memory and planning) requires structure, predictability and skill development.

19. Summary

• Trend in functional imagery research suggesting (at least 4) developmental differences in candidate brain systems/circuits that may convey latent vulnerability for later social and mental health difficulties; even when no difficulties are currently apparent.
• Polarisation of services child welfare/ family support and child mental health is not helpful. Need for ‘stress inoculation’ training; and a structured, preventative approach to skill development in all vulnerable young people and families.

20. Practice Reflections….

• How does information about Developmental Differences align with your current practice and your experience of young people and families?
• How can stress inoculation strategies and skills be made more accessible to young people and families?

21. Selected References….

Ford, T., Vostanis, P., Meltzer, H., & Goodman, R. (2007). Psychiatric disorder among British children looked after by local authorities: Comparison with children living in private households. British Journal of Psychiatry, 190, 319-325. doi: 10.1192/bjp.bp.106.025023

Luke, N., Sinclair, I., Woolgar, M., Sebba, J. (2014). What works in preventing and treating poor mental health in looked after children? NSPCC and Oxford University. https://www.nspcc.org.uk/globalassets/documents/evaluation-of-services/preventing-treating-mental-health-looked-after-children-summary

McCrory, E.J., De Brito, S.A., Sebastian, C.L., Mechelli, A., Bird, G., Kelly, P.A., & Viding, E. (2011). Heightened neural reactivity to threat in child victims of family violence. Current Biology, 21, 947–948.

McCrory, E.J., & Viding, E. (2015). The theory of latent vulnerability: Reconceptualizing the link between childhood maltreatment and psychiatric disorder. Development and Psychopathology, 27, 493–505.

Sheridan, M.A., & McLaughlin, K.A. (2014). Dimensions of early experience and neural development: Deprivation and threat. Trends in Cognitive Sciences, 18, 580–585.

Cortese, S., Kelly, C., Chabernaud, C., Proal, E., Di Martino, A., Milham, M.P., & Castellanos, F.X. (2012). Toward a systems neuroscience of ADHD: A meta-analysis of 55 fMRI studies. The American Journal of Psychiatry, 169, 1038–1055.

Danese, A., Moffitt, T.E., Arseneault, L., Bleiberg, B.A., Dinardo, P.B., Gandelman, S.B., & Caspi, A. (2016). The origins of cognitive deficits in victimized children: Implications for neuroscientists and clinicians. The American Journal of Psychiatry. doi:10.1176/appi.ajp.2016.16030333.

Eysenck, M.W., Derakshan, N., Santos, R., & Calvo, M.G. (2007). Anxiety and cognitive performance: Attentional control theory. Emotion, 7, 336–353.

Holmes, A.J., MacDonald, A., Carter, C.S., Barch, D.M., Stenger, V.A., & Cohen, J.D. (2005). Prefrontal functioning during context processing in schizophrenia and major depression: An event-related fMRI study. Schizophrenia Research, 76, 199–206.

McLean, S., & McDougall, S. (2014). Fetal alcohol spectrum disorders: Current issues in awareness, prevention and intervention (CFCA Paper 29). Melbourne: Australian Institute for Family Studies.

Morgan, A., & Lilienfeld, S. (2000). A meta-analytic review of the relation between antisocial behavior and neuropsychological measures of executive function. Clinical Psychology Review, 20, 113–136.

Rubia, K. (2011). “Cool” inferior frontostriatal dysfunction in attention-deficit/hyperactivity disorder versus “hot” ventromedial orbitofrontal-limbic dysfunction in conduct disorder: A review. Biological Psychiatry, 69, e69–e87.

Sattler, J. (2016). Foundations of Behavioural Social and Clinical Assessment of Children. California: Pro-Ed Australia.

Snyder, H.R. (2013). Major depressive disorder is associated with broad impairments on neuropsychological measures of executive function: A meta-analysis and review. Psychological Bulletin, 139, 81–132.

Snyder, H.R., Kaiser, R.H., Warren, S.L., & Heller, W. (2015). Obsessive-compulsive disorder is associated with broad impairments in executive function: A meta-analysis. Clinical Psychological Science: A Journal of the Association for Psychological Science, 3, 301–330.

Snyder, H.R., Miyake, A., & Hankin, B.L. (2015). Advancing understanding of executive function impairments and psychopathology: Bridging the gap between clinical and cognitive approaches. Frontiers in Psychology, 6, 328.

Willcutt, E.G., Doyle, A.E., Nigg, J.T., Faraone, S.V., & Pennington, B.F. (2005). Validity of the executive function theory of attention-deficit/hyperactivity disorder: A meta-analytic review. Biological Psychiatry, 57, 1336–1346.

22. About the presenter

Sara McLean, PhD 
Adjunct Research Fellow Australian Centre for Child Protection 
[email protected] 
www.fosteringdifference.com.au

23. Continue the conversation…

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