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.