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The NeuroRelational Framework (NRF): Translating Brain Science into Clinical Practice
Connie Lillas, PhD, MFT, RNNRF Global Communities www.nrfgc.com 1
The Neurorelational Framework: Translating Brain Science into Clinical Practice
Connie Lillas, PhD, MFT, RN
www.nrf‐gc.org
Outline
• Our cultural context at‐large; mismatches in neurodevelopment from various venues
• Promotion: Universal Key Concepts About Brain Development
– Brain Architecture
– Serve & Return
– Toxic Stress
• Prevention: Strengthening Connections
– Assess and Support Adaptive vs Toxic Stress Patterns
– Assess and Support the Serve and Return Process of Engagement
• Intervention: Individual Differences & Community Building
– Using Individual Differences for KnowingWhen to Work Bottom up & Top Down
– Building Cross‐Sectored Communities
Compliance vs Non‐Compliance
In our culture, we are taught…
• Challenging behaviors = compliance and non‐compliance
• Solved using rewards and punishments
• Often blame parents
The NeuroRelational Framework (NRF): Translating Brain Science into Clinical Practice
Connie Lillas, PhD, MFT, RNNRF Global Communities www.nrfgc.com 2
National Survey, 2016 ‐ZERO TO THREE
National Survey, 2016 ‐ZERO TO THREE
False Assumptions! Top Down vs. Bottom Up
Top‐Down Capacities
Bottom‐Up Capacities
Face‐Heart Connections!
SAFETY VS. THREAT
The NeuroRelational Framework (NRF): Translating Brain Science into Clinical Practice
Connie Lillas, PhD, MFT, RNNRF Global Communities www.nrfgc.com 3
Mismatch of Parental Expectations
• Our children’s chronological age does not always match his or her developmental age
• Disappointment is unmet expectations, and the more significant the expectations, the greater the disappointment
• The greater the disappointment, the greater the stress response, the greater the chance of toxic stress!
Mismatch within Large Systems of Care ‐ Child Welfare System
• Assume that if parents take a parenting class and go to an Anger Management class that they are ready to reunite
• All top‐down information without any bottom‐up lived experiences for how to manage stress levels, how to repair relationship, and how to get resilience back on line (or begun)
• Knowledge is a Rumor Until it Lives in Your Body
Mismatch of Professional Expectations
• Our medical systems of care often assume that adults make deliberate, top‐down “choices” to be unhealthy or healthy
• Safety vs. threat often is not considered as part ofautomatic behaviors that promote emotional safety even though they may be medically “unhealthy”
• The greater the adverse experiences the greater thechange that toxic stress is driving the adult onset of “diseases”!
>400lbs. (185Kg)
againinashorterperiodoftimethantheweight
waslost.
Weeks
Felitti. 2012
‐Centers for Disease Control and Prevention (CDC) and Kaiser Permanente, 1998‐17,000 middle‐class Americans answered questionnaires‐Past childhood experiencesCurrent health and behaviors
Mismatch of Evidence‐based Treatments
• Our children’s chronological age does not always match his or her developmental age
• When our clinics are parsing out who is getting trained in what EBT and who gets what client, there may be a mismatch between bottom‐up & top‐down needs
• The greater the mismatch, the more the treatment will not work or the longer it will take or the family will drop out
The NeuroRelational Framework (NRF): Translating Brain Science into Clinical Practice
Connie Lillas, PhD, MFT, RNNRF Global Communities www.nrfgc.com 4
Experiences Build Brain Architecture‐Video
https://www.youtube.com/watch?v=VNNsN9IJkws&list=PLI-R9dGMpDvu9YGNjUe5TUSBSREclLwcs&index=5
•Motorplanning•Plan&sequence•Theoryofmind•Language
EarlyCare&Education
•Emotions•Memories•Meaning‐making
• Nutrition•Sleep/awakecycle•Stress&StressRecovery
•Sensations•Processing&Modulation•Speech
DevelopmentalDisabilities
MentalHealth
BasicNeeds/Medical
STEP3:BrainArchitecture‐Micro&MacroLevels
EXECUTIVE
RELEVANCE
REGULAT
ION
SENSORY
Lillas&Turnbull,2009
ChildWelfare
PreventiontoDetention
Serve and Return‐Video
https://www.youtube.com/watch?v=m_5u8-QSh6A&index=6&list=PLI-R9dGMpDvu9YGNjUe5TUSBSREclLwcs
Toxic Stress Derails Healthy Development‐Video
https://www.youtube.com/watch?v=rVwFkcOZHJw&list=PLI-R9dGMpDvv4QT2_eXmXzqyvJw9W8fgx&index=5
Cascade Effect
• Toxic stress disrupts circuits that exist….”estimate that over 80% of foster children they examined suffered from
developmental, behavioral, or emotional problems (between two and eight times the national averages).”
Stock & Fisher, 2006, Child Welfare League
• Neglect disrupts the firing/wiring of brain architecture & circuits
• In 2010 alone, neglect accounts for 78% of all child maltreatment cases nationwide, far more than physical abuse (17%), sexual abuse (9%), and psychological abuse (8%) combined. In Brief, The Science of Neglect, pg 2.
• Finally, the vast majority of children who die as a result of child maltreatment are victims of neglect (72%) alone, or in combination with other forms of maltreatment (DHHS, www.childwelfare.gov, 2014).
The NRF is a framework that translates brain science into practice :
Three Core Concepts:
• Stress Resilience versus Toxic Stress
• “Serve & return” levels of high quality engagement
• Development of brain networks
Assess & Intervene:
• Step 1: Adaptive vs. toxic stress
(roots to a tree)
• Step 2: Age appropriate vs. poor serve and return
(trunk of a tree)
• Step 3: Age appropriate developmental capacities vs. delays or disorders in brain architecture
(branches of a tree)
C. Lillas, adapted from Lillas & Turnbull, 2009
The NeuroRelational Framework (NRF): Translating Brain Science into Clinical Practice
Connie Lillas, PhD, MFT, RNNRF Global Communities www.nrfgc.com 5
1. Adaptive vs. Toxic Stress
2. Serve and Return
3. Strengths & Vulnerabilities in Brain Architecture
Step 1: Adaptive vs Toxic Stress
http://developingchild.harvard.edu/index.php/resources/multimedia/videos/three_core_concepts
Step #1: How do we identify stress & stress recovery ?
A. Recognize three primary stress responses and who we are at our Worst!
B. Recognize four toxic stress patterns
C. Recognize what stress recovery looks like and who we are at our Best!
UCB, C. Lillas, © 2014
What is stress? What does it look like?
• While our culture often defines that our children’s behavior as compliant or noncompliant, our first response needs to understand that this is likely a stress response
• When we are challenged or under threat, there are three Automatic Nervous System stress responses
– Red zone with gas
– Blue zone with brake
– Combo zone with gas and brake
Face‐Heart Connections!
The NeuroRelational Framework (NRF): Translating Brain Science into Clinical Practice
Connie Lillas, PhD, MFT, RNNRF Global Communities www.nrfgc.com 6
Lillas & Turnbull, © 2009
Connie Lillas, PhD, MFT, RN © 2010
Reading Non‐Verbal Cues:Red ZoneA Baby’s Flooded State:
A Baby’s Shut‐Down State
Reading Non‐Verbal Cues:Blue Zone
A Baby’s Vigilant State:
Reading Non‐Verbal Cues:Combo Zone
Arousal Zones Across the Lifecycle
– Green • Calm, alert
– Red• Hyperarousal• Flooded
– Blue• Hypoarousal• Dissociate
– Combo (red/blue)• Hypervigilant• May look calm outside, but anxious inside
& Deep Sleep Cycling
Chronic Stress
Alarm Relaxation
Normal and Long‐term Stress:
The Importance of The First 3 Years Experiences Lay Down Reactions to Stress
The NeuroRelational Framework (NRF): Translating Brain Science into Clinical Practice
Connie Lillas, PhD, MFT, RNNRF Global Communities www.nrfgc.com 7
Step #1: How do we identify toxic stress patterns?
Recognize stress responses that are
too frequent, too quick / intense, too long 4 Toxic Stress Patterns
1. Stress responses that occur too frequently and too quickly– Any color, three or more times a day; intensity level 7 to 10 (0‐10)
2. Prolonged stress responses that take too long to recover – Any color, takes 20 minutes or more to recover
3. Cannot adapt to “normal” challenges and transitions– Any color, caregiver spends 30% or more of day with stress zones due to
transitions or stress zones lasting more than four weeks after a new routine is in place
4. Cannot recover from stress response back to baseline health – Less than 20% green zone, often with disrupted sleep cycle as well
• McEwen (2002); Lillas (2016)Connie Lill, PhD, MFT, RN © 2010
Challenge Your Community’s Assumptions!
Assume “non‐compliant” behaviors emerge from:
Stress responses ‐Threat or Challenge is too great
Differences between chronological age and developmental age
Need for Safety, which comes through relationships
There is a need for co‐regulation & scaffolding
Calm the body and the mind through your relationship
Connect before you correct!
What is Stress resilience on a body level?
• On an Individual Level There Are Two Zones:
– These require conditions of safety
First Deep Sleep Cycle is restorative Second Green Zone when awake
Connie Lillas, PhD, MFT, RN © 2010
What’s the quality of the baby & caregiver’s sleep? • Can your baby get to sleep?
• Can your baby stay asleep?
• Does your baby get enough total sleep?
• Does your baby wake up and feel refreshed?
• Does your baby wake up and feel tired and cranky?
• What about the
caregiver?
UCB, C. Lillas, © 2014
Getting Enough Sleep
https://www.chs-ca.org/_docs/FEP_Sleep_Eng_print.pdf
Newborn with Dad
• https://www.youtube.com/watch?v=TU0f8a3Cizo
The NeuroRelational Framework (NRF): Translating Brain Science into Clinical Practice
Connie Lillas, PhD, MFT, RNNRF Global Communities www.nrfgc.com 8
Step Two: Levels of Engagement
“serve & return”
http://developingchild.harvard.edu/index.php/resources/multimedia/videos/three_core_concepts
“What fires together, wires together”
Strengthening Families and theSix Protective Factors
These can all be linked to relationships!
(1) Parental Resilience (stress recovery)
(2) Social Connections
(3) Concrete Supports in Times of Need
(4) Social Emotional Competence of Children
(5) Healthy parent and child relationships * added
(6) Knowledge of Parenting and Child Developmentwww.strengtheningfamilies.org
Step Two: Levels of Engagement
How “thick” or “thin” is the trunk?
Building on Positive
Procedural Memories
Building on Negative
Procedural Memories
Step Two: Levels One and Two
1. Getting calm (green) together
From birth to three months an infant’s capacity for “Green Zone” grows. When an infant is in the green there is opportunity to take interest in the sights and sounds and movement of the world.
2. When calm able to experience comforting contact through…
making visual contact (eye contact/look at faces), or auditory contact (vocalize or sing together), or movement contact (rock together), or tactile contact (cuddle together), or olfactory contact (smelling together) that you both find comforting & connecting
SE Milestone Language Adapted by Connie Lillas
The NeuroRelational Framework (NRF): Translating Brain Science into Clinical Practice
Connie Lillas, PhD, MFT, RNNRF Global Communities www.nrfgc.com 9
Step Two: Level Three
• When experiencing comforting contact able to share joy.
– During the first four months, infants and parent become more intimate as they interact with warmth, trust. Hugs, songs, looks, dancing and reading together provide opportunities to enjoy each other and fall in love.
– Over time the child will remain engaged across a full range of emotions.
SE Milestone Language Adapted by Connie Lillas
Step Two: Level Four
• When sharing joy, able to create a continuous back‐and‐forth flow of communication
– By nine months, purposeful, continuous flow of interactions with gestures and expressions develops. As the infant gains motor control, the ability to point, reach, grab and drop objects, creep, sit, roll, crawl all support this back‐and‐forth flow.
– “Circles of communication” are when the flow is continuous.
SE Milestone Language Adapted by Connie Lillas
Step Two: Level Five
• When in a flow, able to expand non‐verbalcommunication through an increasingly nuanced ability to read emotional cues, intentions, gestures, and to solve problems.
– By 18 months, the infant has learned the patterns of the back‐and‐forth flow and begins to use this awareness to think about how to solve problems or get what he wants i.e. pulling Mommy’s hand to the refrigerator to get a snack.
– Later, as verbal language expands this task is carried out verbally.
SE Milestone Language Adapted by Connie Lillas
Stress Response System
Rupture and Repair Cycles
Step Two: Level Six & Seven
• Six: When sharing emotions, able to create stories via symbolic play & pretend play, with developing language skills
– Beginning at 24 months, toddlers are able to represent intentions, ideas and feelings in imaginative play or with language using words and toys.
• Seven: When using emotional stories, able to make‐sense and solve problems together
– Emerging during 36‐48 months, children can bridge and combine ideas to use emotions in play to solve problems.
Connie Lillas, PhD, MFT, RN © 2010
As you get more green, go for comfort & joy!
• Some parents never had never had experiences of being soothed with joy themselves or with their child (history of neglect) so there will no gleam in the eye seen with reunions
• Some parents, even with a history of abuse, may have had experiences of joy with their children and the “procedure” of joy can return
• ASK: Do the parents recall any ways they laughed with their baby/child before? How did they use to play?
The NeuroRelational Framework (NRF): Translating Brain Science into Clinical Practice
Connie Lillas, PhD, MFT, RNNRF Global Communities www.nrfgc.com 10
Fostering Family PartnershipsPhilosophy
• #1 goal is to provide “best practice in concurrent planning” by stabilizing the infant’s relationships (step #1, 2, 3)
• #2 be part of a system that provides additional birth parent support through coaching and modeling for reunification
• #3 support opportunities for coaching and mentoring to all involved in infant’s life with your team members
• #4 support “shared parenting” approach between all parents
• #5 provide open‐ended relationships for all parties
Old System
BabyKinshipParent
BirthParent
Shared Parenting –Fostering Family Partnerships
Baby
TherapeuticParent
BirthParent
Adverse Childhood ExperiencesLinear increase in negative health/mental health outcomes as number of adverse childhood experiences increase
Mom’s Events include ‐ 3: Abuse
Physical Abuse
Emotional Abuse
Sexual Abuse
Neglect
Physical Neglect
Emotional Neglect
Household Dysfunction
Family Violence
Parental Mental Illness
Separation or loss of a parent
Parental Incarceration
Parental Substance Abuse
Child’s Events include ‐ 5:Abuse
Physical Abuse
Emotional Abuse
Sexual Abuse
Neglect
Physical Neglect
Emotional Neglect
Household Dysfunction
Family Violence
Parental Mental Illness
Separation or loss of a parent
Parental Incarceration
Parental Substance Abuse
Cumulative Risk Factors
0
1
2
3
4
5
6
7
8
9
Regulation Sensory Relevance Executive
9
3
7
6
4
7
8
4
# O
F R
ISK
FA
CT
OR
S
BRAIN SYSTEM
Vulnerability of 4 Brain Systems
Mom Child
Links to History Worksheet
The NeuroRelational Framework (NRF): Translating Brain Science into Clinical Practice
Connie Lillas, PhD, MFT, RNNRF Global Communities www.nrfgc.com 11
“Just Right”
Spacey
Glassey eyed
Tuned out / Flat
In own world
Flitting
“Tantrum”
AggressiveAnxious
Green= 5%Red=45%Combo=2%Blue=50%
Step One: Child’s Colors
Adapted by Jessica Richards fromInfant/Child Mental Health, Early Intervention and
Relationship‐Based Therapies: A Neurorelational Framework for Interdisciplinary Practice, by Lillas & Turnbull, 2009
Adapted SE Milestones by C Lillas, 2014 BOTTOM UP From Greenspan, 1985; Greenspan &Wieder, 1998; Axis V from the Diagnostic Classification (R): 0-3 (2005)
Step # 2
Level 7. When sharing feelings, able
to make-sense and solve problems
together (by 36 to 48 months)
Level 6. When reading cues, able to share
feelings with others through pretend play
and/or by talking (by 24 to 36 months)
Level 5. When in a flow, able to expand and
read non-verbal emotional & gestural cues
(by 13 to 18 months)
Level 4. When sharing joy, able to create a
continuous back and forth flow of communication
(“circles”) (by 9 months)
Level 3. When making comforting contact, able to share
joy & fall in love (by 5 months)
Level 2. When calm, able to make visual contact (eye contact/look at faces), or auditory contact (vocalize or sing together), or movement contact (rock together), or tactile contact (cuddle together), or olfactory contact (smelling together) that you both find comforting & connecting (by 3 months)
Level 1. Getting Calm (Green Zone) Together
(by 3 months)
TOP DOWN
Levels of Engagement
Step Two Transitions & Challenges
• Following 5 months of Shared Parenting non‐relative foster placement, child was brought back to grandmother’s house
• As a result DCFS required teen mom to have separate housing
• Without stable housing, teen mom destabilized
• Child was in a licensed, yet low quality daycare center with poor engagement and he was sedentary in a high chair
Adapted SE Milestones by C Lillas, 2014 BOTTOM UP From Greenspan, 1985; Greenspan &Wieder, 1998; Axis V from the Diagnostic Classification (R): 0-3 (2005)
Step # 2
Level 7. When sharing feelings, able
to make-sense and solve problems
together (by 36 to 48 months)
Level 6. When reading cues, able to share
feelings with others through pretend play
and/or by talking (by 24 to 36 months)
Level 5. When in a flow, able to expand and
read non-verbal emotional & gestural cues
(by 13 to 18 months)
Level 4. When sharing joy, able to create a
continuous back and forth flow of communication
(“circles”) (by 9 months)
Level 3. When making comforting contact, able to share
joy & fall in love (by 5 months)
Level 2. When calm, able to make visual contact (eye contact/look at faces), or auditory contact (vocalize or sing together), or movement contact (rock together), or tactile contact (cuddle together), or olfactory contact (smelling together) that you both find comforting & connecting (by 3 months)
Level 1. Getting Calm (Green Zone) Together
(by 3 months)
TOP DOWN
Levels of Engagement
Step Two
The NeuroRelational Framework (NRF): Translating Brain Science into Clinical Practice
Connie Lillas, PhD, MFT, RNNRF Global Communities www.nrfgc.com 12
Adapted SE Milestones by C Lillas, 2014 BOTTOM UP From Greenspan, 1985; Greenspan &Wieder, 1998; Axis V from the Diagnostic Classification (R): 0-3 (2005)
Step # 2
Level 7. When sharing feelings, able
to make-sense and solve problems
together (by 36 to 48 months)
Level 6. When reading cues, able to share
feelings with others through pretend play
and/or by talking (by 24 to 36 months)
Level 5. When in a flow, able to expand and
read non-verbal emotional & gestural cues
(by 13 to 18 months)
Level 4. When sharing joy, able to create a
continuous back and forth flow of communication
(“circles”) (by 9 months)
Level 3. When making comforting contact, able to share
joy & fall in love (by 5 months)
Level 2. When calm, able to make visual contact (eye contact/look at faces), or auditory contact (vocalize or sing together), or movement contact (rock together), or tactile contact (cuddle together), or olfactory contact (smelling together) that you both find comforting & connecting (by 3 months)
Level 1. Getting Calm (Green Zone) Together
(by 3 months)
TOP DOWN
Levels of Engagement
Step Two Occupational TherapyTrans‐disciplinary Work
• Meet the child as his/her physical level and where s/he is comfortable
• Rewards emanate through the relationship of role transferring work
Planting Seeds of Connection…May Take Time to Grow
Triggers and ToolkitsOrganize Bottom‐up & Top‐down
STRESS TRIGGERS RECOVERY TOOLKITS
Body (Regulation)
Regulation (Body)
Sensations (Sensory)
Sensations (Sensory)
STRESS TRIGGERS RECOVERY TOOLKITS Feelings (Relevance)
Feelings (Relevance)
Thoughts/Planning (Executive)
Thoughts/Planning (Executive)
Triggers for Mom & Child –Symptoms
• Speech delay (apraxia)
• Lack of joyful exchanges
• Clumsiness, falling and tripping frequently
• Little eye contact or engagement
• Flitting around from object to object
• Marginal green zone
• “Stuffing cheeks” with food
• Profound loss due to adoption
• Mom challenged with multiple demands from Probation and Dependency Courts
Triggers for Mom & Child –Symptoms
• Mom history of Juvenile Hall (trauma)
• Under‐responsive to sensations and facial cues
• Weak visual‐motor coordination
• Lacks core strength
• Mom’s substance use
• Hitting & biting when upset
• Teem Mom’s Immigration, with separation from her own Mother from 2 to 8 years old
• Glassy, glazed eyes
The NeuroRelational Framework (NRF): Translating Brain Science into Clinical Practice
Connie Lillas, PhD, MFT, RNNRF Global Communities www.nrfgc.com 13
Organize the Case Neurodevelopmentally!
Regulation Factors
• Flitting around from object to object
• Marginal green zone
• Mom’s substance use
• Hitting and biting when upset
• Glassy, glazed eyes
Sensory Factors
• Speech Delay
• “Stuffing cheeks” with food
• Under‐responsive to sensations and facial cues
• Weak visual‐motorcoordination
Organize the Case Neurodevelopmentally!
Relevance Factors
• Lack of joyful exchanges
• Little eye contact orengagement
• Mom history of Juvenile Hall (trauma)
• Immigration (trauma)
• Profound loss due toadoption
Executive Factors
• Clumsiness, falling & tripping frequently
• Weak visual‐motor coordination
• Lacks core strength
• Mom challenged withmultiple demands from Probation and Dependency Courts
Toolkits for Mom & Child for Stress Recovery & Resilience
• Short bursts of tasks at school with rewards
• Eye spy games
• Rupture and repair with grandmother
• Ongoing volunteer commitment to family
• Minimizing transitions
• Vestibular and proprioceptive input
• Promoting Mom’s ongoing connection in her son’s life
• Undershooting his verbal production
• Highly structured, routine‐oriented classroom
• One item of food at a time, in small bites
Toolkits for Mom & Child for Stress Recovery & Resilience
• Mom’s sobriety
• Three recesses a day
• High, joyful affect
• Good sleep cycle
• Crawling and yoga ball exercises
• Language enriched, special education classroom
• Processing mom’s losses
• Use of action verbs with gestures
• Neurologist ruled out FASD
Organize the Case Neurodevelopmentally!
Regulation Factors
• Mom’s sobriety
• Neurologist ruled out FASD
• Healthy sleep cycle
Sensory Factors
• Eye spy games
• Minimizing transitions
• Vestibular & proprioceptive input
• Undershooting his verbal production
• Three recesses a day
• Crawling & yoga ball exercises
• Language enriched, special education classes
• Use of action verbs with gestures
• One item of food at a time, in small bites
Organize the Case Neurodevelopmentally!
Relevance Factors
• Short bursts of tasks at school with rewards
• Rupture & repair with grandmother
• Ongoing volunteer commitment to family
• Promoting Mom’s ongoing connection in her son’s life
• High joyful affect for child
• Processing Mom’s losses
Executive Factors
• Language enriched, special education classroom
• Highly structured, routine‐oriented classroom
• Short bursts of tasks atschool with rewards
The NeuroRelational Framework (NRF): Translating Brain Science into Clinical Practice
Connie Lillas, PhD, MFT, RNNRF Global Communities www.nrfgc.com 14
Building a Cross‐Sector Community
•LAUSD, Special Ed
•EARLY HEAD START
Early Care & Education
•Infant Mental
Health Therapist
Request CPP
•FASD Pediatrician
• Developmental
Pediatrician
•Neurologist, CHLA
•South LA RegionalCenter
Speech Therapy
Occupational Therapy
Developmental Disabilities
Mental Health
Basic Needs/Medical
Step #3 ‐Four Brain Systems: Macro & Micro Levels
EXECUTIVE
RELEV
ANCE
REG
ULATIO
N
SENSORY
Lillas & Turnbull, 2009
Child WelfareFoster Care, 7 months
Young Children in Care(YCIC)
• The role of Birth to Five Champions, Two DCFS Administrators trained in IMH – Laura Andrade
– Charisse Pilar
• Eight Service Planning Areas (SPA)
4 hour trainings at each SPA
Multiple trainers, Train the Trainers
Once a quarter NRF case mapping
• Changing our Child Welfare culture!
8 Service Planning Areas (SPA’s)
Avisionaryseeslightinthedark…• Small, volunteer efforts provide a light
• If you are visionary, how can you help spread the light?
Molly Hahn, 2015