World Suicide Prevention Day - Collective Responsibility

N Ireland has the highest suicide rate in the UK. An average of 5 people die through suicide each week. More people have died through suicide since the Good Friday agreement than died throughout the NI conflict.

We have 25% higher overall prevalence of mental health problems than England and the highest rates of self-harm in the UK. Of 30 countries involved in the World Mental Health Survey, N Ireland had the highest rates of Post Traumatic Stress Disorder (PTSD). Drug-related deaths among males in N Ireland (which account for 74% of drug-related deaths) have almost doubled in the last 10 years. Homelessness is increasing and more than 200 people have died while on the homeless register in Northern Ireland within 18 months.

The long awaited Suicide Prevention Strategy - ‘Protect Life 2’ was published today. The strategy sets out what the Department will do to reduce suicide and self-harm over the next five years and looks at the importance of everyone working together on prevention.

It is yet to be seen whether this strategy can meet its objectives, but one thing is for sure - too many lives have already been lost through suicide as well as through drugs and alcohol. We have known too many people through our work and our personal lives whose lives have ended prematurely and they are part of the reason Connected for Life came into existence.

Too many of people in our community are living without hope, choice, belonging, opportunity & connection. Rather than sighing with resignation at this situation, we should be outraged! They are our fellow human beings, they belong to us and we to them. It’s not just the role of mental health services, politicians and policy makers to protect lives, it is a collective responsibility in which we all play a part.

It is all too easy to live in our own bubble and try to ignore the pain and suffering in our society. It is easy to look the other direction in the face of human suffering and to console ourselves with the idea that those experiencing poverty, homelessness or addiction have arrived in that place due to making poor choices and are therefore less worthy of compassion. When children in our communities are engaging in anti-social behaviour or using alcohol / drugs it is too easy to blame the parents or to be one the 35% of people in N Ireland who believe paramilitary attacks, including those against children, are justified. It is all too easy to judge, shame and dehumanise our neighbours when they are most in need of understanding, compassion and connection.

Many professionals working within the field of trauma experience frustration at the limitations and flaws in our systems and how they can even cause further harm. Sometimes it is easier to climb into that bubble again, just get on with it and ignore the bigger picture. We can become so enraged by the flaws in systems that it impacts our own well being and impairs our ability to work most effectively. Rather than bemoaning the toxic systems we work within, we should focus on the difference they do make, do everything in our power to highlight their limitations and do what we can to change them, while looking after our own well being in the process.

One of the reasons we have such high rates of suicide and mental illness is the legacy of the conflict. 39% of the population experienced some sort of traumatic event during the conflict. While others did not directly experience a traumatic event, the experience of living among so much violence and potential danger can potentially impact us all, changing our biology, producing brains and a stress response system primed for danger. These changes transmit to the next generation through epigenetics. So not only are we a collection of traumatised as individuals, but we also live in traumatised communities and work in traumatised organisations. This makes ‘othering’ common within our communities and organisations, making it more likely that communities will turn against those they see as weak or dangerous and that organisations become competitive, rather than collaborative.

This is why we are passionate about building a trauma aware, sensitive, informed and responsive community in Northern Ireland. We need to become trauma aware as individuals, organisations, community and a society. We need to support those impacted by trauma by providing effective services and environments, supported by effective policies and strategies. We need ensure we do not re-traumatise people through judgement, shame and oppression personally, in our organisations, in our communities and as a society. We need to build a community and society that is compassionate, connected, nurturing, vulnerable and forgiving and that values every individual. This is a long way off and we have a lot of healing to do before we get there but we if we all play our part and acknowledge our collective responsibility healing is always possible.

Back to School Stress!

The back to school period can be a challenging and stressful time for families. Many children feel like little boats bobbing about in the water of uncertainty, worry, apprehension or fear. Of course, to stop them being carried out to sea, those little boats need to be connected to a secure anchor. However, as a parent of 3 children, one of whom has just started 'big school' I can categorically say that around back to school time I certainly don't feel like a secure anchor, more like a wobbly jelly! Back to school, changing school or starting school transitions are difficult for us as parents because we worry about our children. Will Amy make friends at her new school? Will John be bullied because he has a disability? Will Lucy be scared when I leave her? Will I be able to afford to keep Matthew at that school with the increasing cost of uniform and other stuff?

My youngest daughter started 'big school' last week. In my 'wobbly jelly' moments I worried that she would be OK, make friends, not experience the anxiety she had in primary school and manage practically  in light of some of the issues she struggles with around motor skills. Then I worried that she would pick up my worry, like the little sponge she is, and that this would make things worse! As I explained in a previous blog, Cara had a traumatic birth, which affected her attachment and contributed to her developing school-related anxiety in primary school.  She overcame this and built her resilience by (as detailed here) developing a great understanding of her brain, body and emotions. This understanding has become part of her language now and she can articulate her emotions very well. When she was reflecting on how she was feeling about starting her new school, she decided that there wasn't a word  to describe how she was feeling.  She labelled the feeling 'nervitement', a combination of feeling nervous and excited at the same time.  

Cara's experience is by no means unique. The transition to a new school or new class is potentially stressful and children's behaviour around this time of transition is best understood as a response to stress. When we are under stress we instinctively respond in one of the following ways - fight, flight or freeze. What does this look like in our children?

Fight response - Aggression, angry outbursts or arguments. This is a hard response to deal with as a parent, especially when you are dealing with your own stress. It can feel personal and intentional. It generally isn't!

Flight response - Running away, becoming upset or trying to avoid the source of stress, in this case school. The stress response is a biological one that causes physiological change. When your child says they have a sore head or sore tummy at stressful times like these, it may not just be a convenient excuse.

Freeze response - Not wanting to talk, going to their room, withdrawing. Sometimes, we don't notice when children are in freeze mode as their behaviour is not causing us to pay attention and they appear to be happy and content. 

How each child experiences and responds to stress will be different, but the universal key to being able to manage stressful experiences is positive relationships. This is a time when children really need to use those relationships with their family, friends and teachers. However, it is often the time that they appear to be doing everything they can to push those they love and care for away!  Children under stress are in distress, even though it may not sometimes appear that way. Their behaviour is not rational, nor indeed intentional, meaning they can behave ways that makes them very hard to like, never mind to love!

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Like so many other children, Cara's first week of school was stressful. In primary school she had responded to school-related stress with a flight response - anxiety, wanting to avoid school, feeling sick, becoming upset. This time, however, her response was totally different. We were introduced to her fight response, which was quite out of character and quite disarming! When I drove her to school, which was what she wanted, she complained on seeing others get off the bus, "this is SO embarrassing!". It was my fault when she couldn't find her books or shoes. After one particularly stressful day, she kept shouting at me for no reason, then apologising after realising what she had said and done. After a while she became exacerbated and said "why am I like this?"

In the past my response would have been to tell her how unacceptable her behaviour was, that I would not be spoken to in that way and she needed to apologise at once. However, knowing that her behaviour was due to stress and out of her control meant that I did not take it personally this time. Giving her the answer to the question "why am I like this?" had made a difference in the past, so I reminded her about what she had learned. We discussed how we can 'flip the lid' in times of stress and how she had learned what helped her 'keep her lid on' - sleeping well, meditation, restricting the use of technology, eating well, exercising - all things that had kind of gone to pot over the summer! We had a laugh about how she would need to bring a hammer to school with her so she would hammer her ‘lid’ down when it starting coming loose. Although this was a bit of fun, she came up with an alternative to a hammer, a gentle tap on her head by her fingertips. This type of tool had helped her in the past, so hopefully it will again. 

When she had dealt with school-related stress in the past she was a child, but she is now moving towards adolescence, a time of huge developmental change, not only in children’s bodies, but in their brains. These brain changes are what cause adolescents to be highly emotional, thrill seeking, risk taking and to seek social approval from their peers. The significant changes happening in children’s brain around the time of adolescence can change how they respond to stress differently, which possibly explained why Cara’s default stress response had changed from a flight response to a fight response. 

Having awareness of how stress affects her and tools to deal with it has been invaluable for Cara and for other children that I have worked with. However, the best tool of all was the big hug and snuggle that Cara and I enjoyed after she discovered that she wasn't turning into a monster and I discovered that my wee girl might just manage this 'big school' journey OK after all. 

Let's talk about PROFESSIONAL LOVE!

We know that a relationship with a caring adult is the key to building resilience in children. For children who have experienced adversity / trauma that one key relationship for them is often with a caring professional in their life.

We often talk to professionals about the role of love in a professional context, so we were delighted when we came across the work of Dr Jools Page who has done significant research on professional love in the early years context. The use of the L word can make people uncomfortable for many reasons. We worry about inappropriateness or allegations, particularly in professions like social work that have been blighted by abuse of the professional relationship. So we often substitute the word love with other safer words / phrases like unconditional positive regard, respect, care or compassion. When we ask ourselves what we mean by these words we use to describe the professional relationship we often mean love, but are too scared or not permitted to use the L word.

When we talk to children who have been buffered by their relationship with a professional in their life and ask them what that relationship felt like, they don't say it felt like unconditional positive regard, respect, care or compassion. They simply felt loved! We were recently delivering a presentation on relationship based practice to student social workers. Marie planned to talk about her work with young people, what they often brought into the room and the qualities of the relationship that made a difference (acceptance, curiosity, active listening, compassion, vulnerability, courage, patience, persistence and hope). She contacted a young man that she worked with 10 ago. He is now a resilient adult who helps us with our work. She asked him if this resonated with him. He told her it did but that she had left out the key word, the one that embodied all those other qualities and had made the difference. Yes, you guessed it – love! This same young man was involved in research on desistance many years ago and told researchers that the key factor that had helped him continue to desist from offending was feeling loved in the context of the professional relationship. 

A lot of the children we worked with had experienced significant hurt in their lives and in turn went on to hurt others. The hurt they caused to others (offending) was what brought them to us. However, we could not address the hurt caused without recognising the hurt they had experienced. Often this hurt had been caused by someone they loved. This left them feeling unsafe, unable to trust others and with a deep sense of being unlovable and deeply flawed. Dr Karen Treisman says that relational trauma requires relational repair, i.e., hurt that occurred in the context of a relationship needs to be repaired in the context of a relationship. To change young people’s deeply held beliefs required us to be persistent, patient, to accept them as they are and actively listen to them with compassion.  It also required courage and vulnerability and for us to hold on to hope, until they were able to hold this hope for themselves. As the young person we described above told Marie, this is love. However, these children were often not ready to be loved and resisted any attempts to treat them with kindness and compassion. Helping them to see themselves as decent human beings had to done gently and tentatively, but with dogged determination never to give up on them.

When we suggest we need to acknowledge and talk about professional love, we are not saying that professionals should run around telling every child they meet that they love them. This would not only be inappropriate, but would be inauthentic. However, we know that the success of our interventions are related less to the theory, method, approach or technique we use and more to the quality of the professional relationship. In most professional environments we regularly discuss our practice in teams, in supervision and attend training to help improve our practice. We talk about our assessment and intervention methods, explore innovative approaches to our work and learn from the successful practice of others. But how often do we really talk about, explore and reflect upon the qualities of our professional relationships? It requires courage to discuss in supervision or with colleagues how you are finding it difficult to warm to a child, to share that you feel that a child dislikes you, or to discuss whether it was appropriate to hug a child when they shared a deeply upsetting story.

We have been very lucky over the past few years to have met and worked with a range of individuals and teams from a range of organisations. We have met many individuals and teams who are courageous and not afraid to embrace vulnerability. They explore and reflect upon the professional relationships they are endeavouring to build. They nurture and pay attention to these relationships in the context of supportive teams. Of course, they also focus on theories, methods, approaches and developing effective interventions and, because these interventions are used in the context of strong, loving professional relationships, they are much more likely to be successful.

Stop the Attacks

I recently attended the ‘At Risk’ Youth Training Conference in Templepatrick, organised by the Education Authority, following a very warm invite from our talented and indefatigable colleagues from St Peter’s Immaculata Youth Centre, Divis.

To a packed room of approximately 200 hundred youth work professionals and some teachers, we heard from a host of eminent speakers about the horrific and long term impact of paramilitary shootings and beatings upon young people, their family, friends and of course the wider Northern Ireland community.

Arlene Kee, the Education Authority’s Assistant Director of Youth Services opened the Conference by outlining the Fresh Start Agreement, the Executive action plan on tackling paramilitarism and organised crime established in 2017. She explained how, as part of a four year programme of work, a number of areas across Northern Ireland have been identified for significant Capacity building.  There are number of Programme objectives one of which is to ‘Identify effective pathways for engagement with children and young people at risk’. Given the complexities and nature of this intractable problem, targeting ways to engage the voices of children and young people in solution focused dialogues, should indeed be the basis upon which to begin this work.

Paul Smyth, one of the leading researchers in this field here in Northern Ireland,  shared many of the key findings pertinent to this issue. This was certainly a wakeup call for me and reminded me why we need to focus our efforts in order to stop this problem in its tracks. Many of the findings struck a chord but those which stood out for me were the findings that:

  • over the past 40 years of our conflict, around half of the victims of attacks are under 25 years
  • many of these children had very difficult childhoods and very complex issues, including substance abuse, learning difficulties, mental health issues
  • many had also been in and out of custody prior to the attacks.  

Paul summarised this very poignantly suggesting that many of these children were ‘often very broken already’. This reinforced my own view that adverse experiences in childhood, especially those driven by poverty and social disadvantage, operate like a vortex, with powerful magnetic effect, drawing in other adversities and creating a toxic mix which is difficult to quantify, but much harder to escape from! 

I am very fortunate not to live in a part of Belfast where such attacks are commonplace and as a Mother I am deeply grateful for that. Paul’s findings were a welcome, much needed, if deeply uncomfortable reminder of just what it’s like to  live in a family where the fear of such brutality is a daily occurrence. This reality was made all the more poignant for me as some of these children, young people and families live less than  3 miles away from my own doorstep. My capacity to ‘turn a blind eye’ or not to fully witness and process the horror of these attacks is perhaps not entirely uncommon among the general population, as many of us do not have to experience this trauma in our daily lives.  When I worked in Youth Justice I was certainly much more aware of the impact of such attacks, having worked alongside a number of young people who had been brutalised in this way.  Paul's presentation of a case study helped bring into sharp focus the full nature and traumatic impact of the lived experiences of these young people, as well as the trauma experienced by those who love and live to protect them.

Over the course of the day we were urged to reframe our thinking and language around these attacks, not to describe them in terms of punishment. Reframing punishment as torture is an infinitely more appropriate description, due to the traumatic impact of such attacks.

We heard Duncan Morrow (University of Ulster) speak about the ethical challenges and dilemmas which both professionals and Communities face as we endeavour to address this problem. This was another important prompt for us during the Conference, to reflect more deeply on a problem which essentially perpetuates because it feeds fear, encourages tribal thinking and is therefore inherently divisive. The phrase ‘no smoke without fire’ comes to mind as many of us have heard, even within our own families, the expression “well he must have done something to deserve it”. This mindset is not an easy one to shift and Duncan urged a note of caution to those invested in addressing this problem, summarising what we all know to be true, that there are ‘no simple glib answers’. Duncan encouraged those present to recall some of the basic principles of youth work practice, which I found really useful:

·         Every human counts

·         Every young person counts

·         Every at risk young person counts

Dr Duncan Redmill  (Head of Trauma Royal Victoria hospital Belfast), an eminent surgeon who treats the victims of paramilitary attacks, presented some of his findings on both the long term physiological as well as the associated psychological impacts of such attacks on victims and the wider community.  Dr Redmill’s address to the Conference was sobering and brought to the forefront of our consciousness the real and lasting traumatic impacts of such attacks.

Detective Chief Superintendent Tim Mairs, (PSNI) and Donna Whyte (DOJ) spoke about the challenges ahead as we strive towards developing a culture of Lawfulness and was realistic in suggesting that many Communities have lost confidence in the formal Justice systems.  Amongst other insights during their presentation, I was particularly struck by the analogy they highlighted between paramilitary attacks on young people and domestic violence, both intimidating their victims through physical or the threat of physical attack, psychological as well as financial control.

What I came away from this conference with was the knowledge that this problem is alive and well and continuing to grow in our culture. I came away with a sense that our community here in Northern Ireland needs to engage in safe dialogues. We can then, together, find our courage and our voice, to say that it’s not OK and it has never been OK to shoot and maim our children and our young people. If we need an example to be led by, then we may well find it in the hearts and mind of youth work professionals. They have worked tirelessly for years, very often behind the scenes and at great personal cost, to protect, nurture and champion our most at risk and hurt children and young people.  

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The Tree of Interaction

An interaction is much more than what each person involved says or does.  The Connected for Life Tree of Interaction shows the complex interplay of behaviours, narratives and histories that is taking place, usually without our knowledge, during every interaction, whether it is a conversation with your partner about whose turn it is to put the bins out or a one to one session with a service user about a painful subject.  

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What we feel, do and say

 

 

 

 

 

 

 

What we believe or value

 

What we have experienced

 

 

 

Most interactions involve more than two people, directly or indirectly. For simplicity, our tree represents an interaction between two people only.

The left side of the tree represents what one person brings to the interaction, while the right side represents the other person. What we present to the world, our behaviours and actions, is only a small part of the story. Our behaviours and actions are determined by our thoughts, prejudices, values and beliefs. Underlying all of this, usually unconsciously, is the influence of genes, how these genes are expressed (epigenetics), temperament, prenatal, birth and early experiences, attachment experiences, intergenerational trauma and family scripts (beliefs held by or behaviour patterns within a family).  
 
Without awareness, the 2 narratives can collide, negatively affecting one or both people in the process.  For example:

  • A simple word / sentence uttered by a partner can trigger early attachment wounds, resulting in conflict. For example, the words “don’t be stupid” may be said in jest during a conversation. However, these words may have been used by a parent who was abusive and therefore may be experienced as hurtful, critical and a threat to the relationship.  
  • A parent may treat their child punitively and harshly because of strong, long held family beliefs about adults being powerful and children being submissive.  
  • A Social Worker who experienced neglect as a child may be quick to judge a parent who is experiencing post-natal depression and is struggling to look after their child.  
  • A manager may be more likely to ignore conflict within the team if they have developed an ‘avoidant attachment style’ at an early age.  

However, with awareness, vulnerability and compassion the interactions can be very different:

  • If the partner recognises his / her feelings of hurt as an early attachment trigger and shares this with his / her partner, a conversation may open up that brings increased connection and has the potential to enhance the relationship. 
  • If the parent becomes aware that for generations his / her family of origin has held the belief that adults should be powerful and children submissive, they may make a conscious decision to do things differently. They may change the belief to a new ‘corrective script’ that suggests that both adults and children deserve respect and therefore treat their child with kindness and compassion.
  • If the Social Worker recognises their judgemental thoughts as sadness and anger about personal experiences, they may be more likely to view the parent with compassion and to provide support.  
  • If the manager becomes aware of his / her avoidant attachment style, he / she is then likely to recognise that sound management decisions must be based on the current situation rather than an intuitive tendency towards conflict avoidance. This may result in a change in management style, leading to more positive decisions for the team.  

©ConnectedforLife, 2016

The NI Resilience Tour

The Northern Ireland Tour of Resilience began on 26th June 2017 with our premiere in Belfast.  We facilitated 5 further screenings in September 2017, in Downpatrick, Derry / Londonderry, Omagh, Portadown and Antrim.

Around 650 people attended those screenings and shared what they heard in their workplaces, communities, families and with their friends. The Tour of Resilience in N Ireland followed the Resilience Scotland Tour and took place at the same time as many screenings throughout the UK. The screenings have resulted in an explosion of interest in the film and in the concept of ACEs generally.  We have facilitated many private screenings of Resilience since for organisations and groups and have now shown the film to well over 1000 people and hope to continue to increase these numbers. 

This film is only part of the journey towards making N Ireland a trauma informed society. There have been many exciting events happening in N Ireland recently, including the first Northern Ireland Adverse Childhood Experiences conference on 13th November. These events suggest that, as a community, we are starting to sit up and take notice of the powerful and far reaching impact of childhood adversity, to endeavour to prevent it and support those impacted by it. 

Children's Mental Health is more important than Academic Achievement

I recently read this article, entitled, 'Why children's mental health is as important as academic achievement'. As a parent who has a child completing the N Ireland transfer tests this year I couldn't agree more. I would even go one step further and say my children's mental health is much more important than their academic achievement.

I did the 11+ myself many years ago and my older children went through it also. This year is my first brush with the new style transfer tests. For those of you not familiar with our transfer process from primary to post primary, this is what happens in N Ireland. Children are tested at age 10 / 11 and their scores determine whether or not they are eligible to attend our grammar schools. Until 2008, this involved children sitting the 11+, 2 tests a couple of weeks apart in their own schools. When this was abolished in 2008, grammar schools unofficially started using new tests to select pupils, the AQE and the GL. For many children this means completing 5 different tests on 4 consecutive Saturdays, often in 2 different grammar schools.

There is no doubt that our grammar schools in N Ireland produce excellent exam results. The current system of academic selection should mean that every child should has opportunity to attend a grammar school. Coming from a family with very limited means I personally benefited from a grammar school education, as did my brothers.

However, I know that some children's mental health has been detrimentally affected by undertaking these tests. I have spoken to parents who have watched their children struggle with serious anxiety triggered by exam stress. The number of counselling sessions delivered to children by Childline NI about exams is increasing every year. Ask any N Ireland GP and they will have seen children recently who are struggling with stress and anxiety related to the tests.Children are crying and even vomiting on the way to, or even during the tests. At age 10 or 11. That is simply not right! These children have brains and bodies that are still developing. And what about when the results come in? Children either get the required results, ie, they pass and are able to attend their school of choice or they fail and are not. Most parents work really hard to convince their children that it really doesn't matter and they will be loved no matter what. As a 10 or 11 year old can you really accept that? Or does 'I am a failure' become one of the core beliefs that affects you throughout your life. 

My late father was one of the most intelligent men I have ever met. However, as he frequently told us, he 'failed' his 11+. He was bullied in school and felt that this detrimentally affected his performance. However, even knowing that there was a context to this failure didn't help. He never really got over it. Even as a man in his 60s, he still felt like a disappointment. Was failing the 11+ an Adverse Childhood Experience? It isn't cited in any ACE study I've ever seen, but it most definitely was for him. It led to toxic stress, deeply affected his self esteem and the emotional memory of being a failure was often triggered in his life. He encouraged us to achieve academically and he was so proud that every one of his 3 children passed that dreaded test. 

Fast forward to this month and my daughter Cara. I have shared before how she dealt with anxiety a few years ago. The build up to the transfer tests was difficult and the anxiety seemed to resurface somewhat, especially when hurricane Ophelia decided to take the roof of our house with it! We should have been doing practice tests and spending precious family time together. Instead we spent weeks freezing, unable to access our upstairs bedrooms, sleeping on blow up mattresses and moving buckets and blankets around to soak up the leaks. We moved into rented accommodation a few days before the transfer test, which was again stressful and difficult. I was already feeling pretty stressed, but I also worried constantly that the whole situation would be too stressful for Cara and would undo the amazing progress she had made over the previous years. I spent a lot of time reassuring her, helping her feel grounded, safe and secure. This wasn't easy as I wasn't feeling entirely grounded, safe and secure myself!

She got through the day of the test OK. I think one of the things that helped her most was that she had been told again and again that it was optional. We are lucky that our local secondary school is great and she would be happy to go there. This meant if, at any point, even on the morning of the test she didn't want to do it, there would be no questions asked. This helped her feel safer and the test to feel less scary. I wonder what it would have felt like for her had that not been an option. I wonder if there are children who's mental health will be detrimentally affected in the long term. I wonder if there are children, who, like my daddy, will go through life with a sense of being a failure. 

I am not an educational expert and I have no suggestions for an alternative to the current process. The above is simply my personal experiences and reflections on the process of academic selection in N Ireland. I know that some children will breeze through the transfer tests. Others will find it a little bit scary, but manage it OK and learn a lot in the process. I also know that parents can choose not to register their children for it. However, there are simply too many children to ignore, for whom the impact of the current process of academic selection will be an Adverse Childhood Experience. 

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Why are ACEs transmitted across Generations?

We recently read the following article, entitled 'Why Unloved Daughters Struggle to Escape Shame'. We have worked with many people who have grown up feeling that one or both of their parents didn't love them. Some of these parents have struggled to fully connect with their own children, even though they desperately love them and they feel deep shame about this.

Feeling unloved as a child creates a deep sense of shame and a core belief throughout life that you are unlovable, bad or flawed in some way.

When a child grows up with the experience of feeling unloved this does not necessarily mean that the parent or parents in question did not love that child. Parents who themselves have experienced adversity in childhood arrive at parenthood with a deep sense of shame and a core belief that they are unlovable, bad or flawed. This can lead to a sense of not being good enough as a parent or feeling frightened, powerless or angry in the face of their child's emotional distress.

When faced with their child's distress these parents may believe they are not able to soothe or comfort their child, which exacerbates their sense of being bad, flawed or simply not being good enough. They may:

·         become angry with their child, which may result in physical abuse.

·         become distressed, which may lead them to turn to alcohol or drugs to self soothe.

·         feel powerless and believe that their child would be better off without them, which may lead them to reject their child.

These behaviours not only cause their child to grow up feeling unlovable, unwanted or rejected, they also cause the parent to feel even more shame, rendering them even less able to deal with their child's distress in future. 

There are many reasons why ACEs are often repeated from generation to generation, including epigenetics, the impact of toxic stress on the brain and body and attachment and self-regulation issues. However, it is very clear that hurt people can hurt people.

The key to preventing this cycle is awareness and courage. Understanding and making sense of our own childhood experiences is the greatest gift we can give to ourselves, our children and our children's children. We have both seen many examples of families in which problematic intergenerational patterns have been stopped in their tracks. This occurs when a brave and courageous individual comes to an awareness that there is a pattern that needs to be broken and makes a conscious decision not to replicate what happened to them. It is never easy, but with support from others, strength and resilience, intergenerational transmission of ACEs does not have to be the norm. 

N Ireland Premiere of the documentary Resilience

The N Ireland premiere of the award-winning documentary Resilience took place in Belfast on 26 June 2017 and was hosted by Dartmouth Films and Connected for Life. 

The event generated great discussion about the far reaching impact of Adverse Childhood Experiences on physical and mental health, as well as social outcomes. The message from the film was one of hope and it was acknowledged that there is some great resilience-building work taking place in N Ireland. There was a great interest in collaborating to raise awareness of these issues, including the suggestion of a ACEs Awareness week throughout N Ireland. 

Some of those who attended the event shared their key insights.

The Adverse Childhood Experiences (ACE) study

The Adverse Childhood Experiences (ACE) study (Felliti et al, 1998) was one of the largest investigations ever to assess the association between childhood maltreatment and later health and well-being. It began in the 1980’s, when Dr Vincent Felliti (from Kaiser Permanente’s Health Appraisal Clinic in San Diego) became exasperated by the high drop-out rates in his obesity clinic, despite evidence of significant weight loss. He stumbled upon a link between the development of obesity and childhood sexual abuse. He collaborated with Dr Robert Anda, a researcher from the Centres for Disease Control & Prevention to carry out a study to explore the association between childhood experiences and health throughout life. The study involved over 17,000 people. They were asked about their health history as well as their childhood experiences, specifically the following:

The results of this research was shocking in many ways:

1.    ACEs were found to be common:

2.   The more ACEs experienced by an individual in childhood, the greater the risk of developing a range of mental, social and physical health issues as an adult. Those who had experienced 4 or more ACEs were more likely to experience health problems or engage in health risk behaviours:

They were more likely to have experienced or perpetrated violence and to have been in prison:

The study also found that, on average, people with 6 or more ACEs die 20 years earlier than those with none. How does adversity lead to these outcomes? Exposure to persistently high levels of stress causes physiological changes to the brain and body and can lead to self-soothing behaviours, such as smoking and substance misuse, which compromise health and well-being.

Participants in the original ACE study were mostly white, middle class and college educated adults. Paediatrician Nadine Burke Harris (2011) carried out research with her patients in a socially deprived area of San Francisco. One of the findings was that children with 4 or more ACEs were more than 32 times more likely to have learning and behaviour problems in school than those who had none.

The original ACE study has been replicated internationally. National ACE studies have been carried out in England and Wales and in some local districts. The English study (Bellis et al, 2014) found that almost half (46%) of the adult population in England had at least 1 ACE, while 8% had 4 or more. As in the USA, there was a strong link between number of ACEs and health outcomes. Individuals with 4 or more ACEs were 3 times more likely to smoke, 7 times more likely to have been involved in violence in the past year and 11 times more likely to have ever been in prison.

The Welsh study (Bellis et al, 2015) found that almost half (47%) of the adult population in England had at least 1 ACE, while 14% had 4 or more. It found that individuals with 4 or more ACEs were 4 times more likely to be a high risk drinker, 6 times more likely to be a smoker, 16 times more likely to be a crack cocaine or heroin user, 15 times more likely to have been involved in violence in the past year and 20 times more likely to be in prison during their lives.

While there has been no Northern Ireland ACE study, an ACE prevalence study was carried out with Queens University students (Spratt and McGavock, 2014) to explore the link between prevalence of ACEs in the University population and contact with Social Services. More than half the study population (56%) reported at least 1 ACE, with 12% reporting an ACE score of 4 or more.

References

Bellis, M. A., Hughes, K., Leckenby, N., Perkins, C. and Lowey, H. (2014) ‘National Household Survey of adverse childhood experiences and their relationship with resilience to health-harming behaviours in England’. BMC Medicine. 12(72).

Bellis, M. A., Ashton, K., Hughes, K., Ford, K., Bishop, J., and Paranjothy, S. (2015) Adverse Childhood Experiences and their impact on health-harming behaviours in the Welsh adult population. Cardiff: Public Health Wales.

Burke, N. J., Hellman, J. L., Scott, B. J., Weems, C. F. and Carrion, V. C. (2011) “The Impact of Adverse Childhood Experiences on an Urban Paediatric Population,” Child Abuse and Neglect 35 (6).

Felitti, M. D., Anda, R. F., Nordenberg, M. D. et al (1998) ‘Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study’ American Journal of Preventative Medicine. 14.

Spratt, T., McGavock, L. (2014) ‘Prevalence of Adverse Childhood Experiences in a University Population: Associations with Use of Social Services’. British Journal of Social Work. 44 (3).

Cara's Lessons in Anxiety Management

I have a background in Psychology and Social Work, so when Cara was born in 2006, I knew about attachment and to a lesser extent trauma and brain development. However, when I began to realise just how deeply her experiences had affected her, a desire to more fully understand this was one of the things that pushed me to learn more about these subjects. This understanding was difficult and painful initially. Like most parents, I felt guilty that my baby hadn't experienced the warm nurturing start I wanted so very much for her. However, when I was able to forgive myself for whatever it was I was supposed to have done, I was able to use the knowledge to help me understand her needs and her behaviour.

What caused Cara most distress from infancy was separation. When she was 9 months old I returned to work part time. Our work schedules meant that we needed to use daycare only one day per week, but what a day that was! As expected she became very distressed when we left her off initially. However, this continued beyond the expected 'settling in' period. In fact, it continued for most of the 3 years she was there. On many occasions I rang my husband in tears, saying I was going to leave my job. You are probably thinking that I should have found another nursery as she wasn't happy, or better still stay home with her. However, it wasn't that I didn't have confidence in the quality of the childcare. I knew the owner and trusted and respected her, the other staff and was happy with how she ran the nursery. I also knew other parents whose children attended and they were all happy. I wasn't in a financial position to pay my mortgage without my salary and had already reduced my hours as much as I could to spend as much time as possible with Cara. When she got old enough to talk about it, she was able to tell us that she liked the staff in the nursery and enjoyed it there. She didn't know why her tummy got sore and she got really upset when she went, or even when she thought about going. This visceral reaction to separation was to become a pattern for childhood anxiety.

I hadn't begun my exploration of attachment, trauma and the brain at this stage so had no idea that the reason Cara responded with such intense emotion to separation was because it triggered implicit memory related to those early days of her life. It was only when she attended playgroup and school that I began to understand what was happening. Playgroup was relatively OK. However, when she went to school things became really problematic, especially as she got older. We had lots of sore tummies, tears and clinging to me in the cloakroom. She had a deep fear that no-one would pick her up from school or that we would be killed in a car crash on our way. She was very articulate for her age, so we were able to have lots of conversations to try to get to the bottom of where these beliefs came from, but again Cara couldn't explain it. She said that, while her head knew for sure that she would always be picked up, she couldn't help how her body (in her case, her tummy and her heart) reacted. It was as if her body did not believe what her head told her.

Cara's first day at school

By this stage I knew enough to understand that her anxiety was not due to conscious thought processes, but a visceral response to an implicit memory of early abandonment. There were times when I couldn't see how we were going to get through this, especially when I was busy, stressed, tired or simply embarrassed because my daughter was screaming and clinging to me in the school cloakroom, while other children skipped into the classroom. But deep down, I knew that it wasn't the end of the world and that we could change things together.

It wasn't easy, but we did get through it together. Cara has found ways to manage her big emotions (in her case fear) and learn to calm herself. Some of the things that have helped her:

Cara's understanding of her brain

Cara's understanding of her brain

1. Understanding her brain - I explained the brain to Cara in simple terms and she totally got it immediately. She also found Dan Siegel's analogy of 'flipping the lid' helpful. She talked about the upstairs and downstairs brain (which we later discovered is in Dan Siegel's 'Whole Brain Child' book) and how her lid flipped when she worried about not being collected from school or when she was being left off in the morning. Watching the film 'Inside Out' added to this understanding. She decided that Joy lived upstairs while Fear and the other emotions (anger, sadness and disgust) lived downstairs. She described how, when her lid flipped, the stairs moved with the upstairs floor, so Joy was not able to talk to Fear to calm it down. 

2. Knowing what to do when the lid does flip - While lid flipping incidents are few and far between these days, they do still happen occasionally. Cara went to some sessions of CBT (Cogntive Behavioural Therapy) when things were at their worst. These sessions encouraged her to reflect on her thoughts, in terms of whether they were helpful or unhelpful. Cara pointed out that focusing on thoughts when she had flipped her lid was pretty pointless. Why? Because thoughts live upstairs and this part of her brain can't be accessed when she has flipped her lid. This was a very valid point. When we are triggered and in states of anxiety or anger, we are not present in our bodies, or in the moment. We are in our heads, letting our thoughts take us on an unhelpful mental journey. Grounding techniques help us to get out of our head and back into out body. There are many such techniques, including breathing, naming what you are feeling, getting back into your body (self hug, hug from someone you love, movement, tapping) or focusing on your senses. Thankfully Cara hasn't had to use these techniques recently, but it is helpful that she has these to fall back on if she needs them. This means she doesn't get into the cycle of being afraid of the fear, which is what feeds anxiety.

3. Understanding of how her brain and body are connected - Cara understands her body more and how it is connected to her brain. She knows how she reacts to worry and stress (she gets a sore tummy and heart, faster heartbeat, clenched muscles). Therefore she can notice when things are getting little stressful and she is more likely to get triggered. At this stage both her upstairs and downstairs brain is online and she can keep herself calm by reason. Joy can still come down the stairs and talk a bit of sense into Fear, to calm down those worries.

4. Keeping the lid on as tightly as possible - Cara now understands that there are some things that help her maintain a sense of calmness and other things that don't. Nightly meditation helps a lot (this is her favourite). Technology doesn't! Like most children her age, Cara would play Minecraft and Roblox all day if she could get away with it. It is restricted to weekends in our house, but she knows that when she uses technology too much she is more likely to get anxious. She won't always admit that of course!

These are just some of the things that have been helpful for Cara in dealing with anxiety. Every child is different and anxiety manifests in different ways. However, some of the principles of how anxiety works and what keeps it under control are universal. 

I am so proud the amazing, confident, articulate and strong girl Cara has become, as she has found her way out of anxiety. She has been able to do this through awareness of how her body and brain work, along with some simple techniques. Anxiety is a huge problem for children today. If you have a child who is experiencing anxiety or work with children, I hope Cara's story has been helpful. I'll now let the lady herself tell you about her journey...

Attachment and Anxiety in Children

When people hear that a child is 'insecurely attached' they often assume that this is due to neglect, abuse, inconsistency or rejection by parents. This is the case sometimes, but often children raised by loving and caring parents can be insecurely attached. While insecure attachment is not the end of the world (around half the population is insecurely attached) it can lead us to feel less safe, secure and less able to regulate our emotions, which can lead to a range of challenges.

My youngest daughter, Cara, has had to face some tough challenges in her life due to insecure attachment. She had a pretty traumatic start in life. She was in occipito posterior position (her back was against my back, while her feet and hands were against my tummy) during pregnancy and labour, which led to 'fetal distress'. During delivery her shoulders got stuck on my pelvis (shoulder dystocia). She was not breathing when she was born and began to have seizures. She had to be moved to a hospital 20 miles away with a neonatal unit, while I stayed behind to deliver the afterbirth and wait a couple of hours for an ambulance to bring me. My husband drove behind the ambulance to be with her. At this stage we were not given any guarantee that she would survive. 

The first day was the hardest. As a newborn baby, what she needed most were food and connection, but meeting those needs threatened her survival. Seizures were triggered when she was touched or tube fed. Therefore we were not able to hold or even touch her and she was only fed minuscule amounts of food, which were gradually increased over a number of days in amounts that she could tolerate without triggering a seizure. She cried with hunger and pain and there was nothing we could do to soothe her. She cried so hard that she lost her voice and all that remained was a croak. We sat beside her bed and talked to her and reassured her as best we could. I kept touching her through the incubator, even though I was told not to, but it was not enough. What my baby needed was for her hunger to be alleviated, for her daddy and I to hold her skin to skin, wipe those tears away and kiss them dry.  We couldn't do this for good reason, but she didn't know that. All she knew was that we didn't and her body and brain adapted to this reality.

Cara was born at full term and weighed a healthy 9lb. However, like all babies, she had an underdeveloped brain, which would develop rapidly in those early days, weeks and months. Babies are totally helpless and dependent and would literally die without someone to look after them. Their behaviour is designed to elicit the love and connection that will ensure their survival and help their brain to develop. Why did Cara cry until her little voice couldn't make any more sound? To elicit the love and connection she needed to ensure her body got the food she needed to survive. It didn't work. Of course this was not intentional and we would have given anything to be able to comfort and soothe her. She didn't know this. Her developing brain simply knew that her most basic needs for food and comfort were not being met, which was a very real threat to survival. We often read shocking stories on television or newspapers about babies who were dumped in bins or abandoned at the roadside. Cara's experience of the world in those early days was no different than the experiences of those babies. It didn't matter that it wasn't intentional or that it was for her own good. All Cara knew was what she was experiencing and that wasn't pretty. 

When a baby does not consistently have their needs for safety, security and connection met, they adapt to best manage in that environment. This is the essence of attachment. 

““our earliest experiences as babies (and even foetuses) have much more relevance to our adult selves than many of us realise. It is as babies that we first feel and learn what to do with our feelings, when we start to organise our experience in a way that will affect our later behaviour and thinking capacities” ”
— Sue Gerhardt (2015) Why Love Matters, P11
Cara 1.jpg

Cara's earliest experiences were stressful and her needs were not met. No-one was there to help her calm down when she experienced big and scary feelings. However, after a week she stopped having seizures and got out of the neonatal unit and a few days later got home. She was able to feed, be held and comforted. She went from experiencing abandonment to experiencing love and nurturing in a short time. While she needed and craved love and affection, the massive change in what she was experiencing probably felt confusing and inconsistent. 

Of course, the concerns about her health didn't just end the minute she got home. We had to wait and see if she developed normally or experienced any problems as a result of her early trauma. She regularly attended physio and was monitored to check whether she was meeting her milestones. This meant that those lovely experiences like rolling over for the first time were fraught with stress. I remember her rolling over for the first time the day before attending a physio appointment. I was over the moon as I was worried about what it would mean if I had to report that she hadn't met that particular milestone. We loved and adored her, but during the first years of her life there was a looming shadow of 'what if....', which led to an undercurrent of worry and stress. Babies are very tuned in to emotional cues, so this may have had an impact on Cara's stress hormones too. 

Cara's early experiences did affect her later thinking and behaviour. She cannot recall these experiences, but this does not mean her body and brain do not remember them. What we don’t remember with our mind, we remember with our heart and gut (implicit memory). She has always found separation difficult and distressing. She developed anxiety about going to school and worried that her dad and I would not pick her up from school, even though this had never happened. She told us that while she knew in her head that her dad and I would always pick her up and she had no reason to think otherwise, her stomach told her something else. Cara attended CAMHS (Child and Adolescent Mental Health Service) and was assessed as being insecurely attached (anxious / ambivalent) due to birth trauma and early separation. 

I am sharing the experiences of my family because, during Connected for Life training and parents groups, so many people have told me about their experiences of having a child in neonatal care or a child who is experiencing anxiety. The statistics are startling. According to Bliss, 90,000 babies in the UK are admitted to neonatal care every year, 1800 of those are in N Ireland. According to NHS Choices, nearly 300,000 young people in Britain have an anxiety disorder. 

There is good news though. It is now understood that the brain has the ability to rewire itself and form new neural connections throughout life. This means that we have the ability to rewire the brain. My next blog will share how Cara has been able to rewire her brain, learning to manage her emotions and understand how her brain and body work.