 Hi, I'm Lucy Brogdon, Chair of the National Mental Health Commission Advisory Board. Welcome to this online conference. What an innovative approach to sharing knowledge and learnings right across the country. I understand there are thousands of you online ready to learn and work. The Mental Health Professional Network is truly taking a novel way to share wisdom with all of you and it's to be applauded. Working Better Together is the theme of this conference and it's a great opportunity to learn more about mental health in the military, about grief and loss and about trauma and adverse childhood experiences. All important topics that need our best attention and our best minds tackling these issues. We know the issues faced by our military and the risk to develop mental illness. We also know there are protective factors. This conference will bring together that conversation and work out how we best protect our serving people. Grief and loss affect all of us at different stages in our life. Understanding what drives that in people and how to best support them in their journey is really important. One of the frustrations for me at the National Mental Health Commission is seeing how stubbornly our incidence of mental health sits when we look at other non-communicable diseases. And what we know is that it is trauma and adverse childhood experiences that often lead people to a journey in the mental health system. If we can better address those experiences in childhood, prevent them, mitigate their impact and try and understand trauma, we set so many people on a more positive journey through life. Thank you all for coming online to join the conference and to be part of these important conversations. I wish you every success. Thank you. Hello everybody and welcome to tonight's online conference, Working Better Together and as part of that Emerging Minds and MHPN jointly bring you our series on adverse childhood events and in particular regarding infant and child mental health. We're really pleased to be able to bring you tonight's presenters and tonight's content and there's about 725 of you who have joined in for this webinar so far tonight. So we welcome each of you and look forward to tonight. We also welcome the viewers who are watching this through podcast. And thank you all for your interest in the online conference. So far we've got over 7000 registrants for the conference, the online conference for which tonight's webinar is part of that. Before we get started tonight, we'd like to acknowledge the traditional custodians of the land across Australia which you all join us and we wish to pay respects to the elders past, present and future, for the memories, the traditions, the culture and hopes of traditional and indigenous Australians. This webinar is the first activity in the trauma, the impact of adverse childhood experiences stream in MHPN's online conference, Working Better Together. So welcome. We've got a great panel for you tonight. My name's Dan Moss and it's a pleasure for me to be facilitating tonight on the Workforce Development Manager at Imaging Minds. And joining us tonight are Professor Kirstie Douglas, Nicola Palfrey and Dr. Elizabeth Heim. So we might start with you Kirstie if we can. You've got a really great experience both as a GP and as a researcher. So I'd just like to know from you before we start, what have you become most interested in in terms of thinking about adverse childhood experiences on children? Well Dan, I'm a researcher but my research really hasn't been so much in the adverse childhood experiences up until more recently. I really became interested in adverse childhood experiences through my clinical general practice and as I worked with women who survived domestic violence, as I was dealing with people with a lot of chronic illnesses such as obesity and stuff, more and more if I asked about previous adverse experiences I just found they were everywhere to be seen. So it was really through an gradually increased understanding of just how prevalent they were amongst adults that I was seeing that I thought well surely we need to know more about this and understand it better so that we can intervene earlier. So it was really from a clinical presentation point of view that I became interested. Thanks for that Kirstie. Our next panelist tonight is Nicola Palfrey. Nicola, as a psychologist, what are the fundamental approaches that you have used in working with children who have experienced adverse childhood experiences? Hi Dan and thanks for having me. I think in the work that I've done with children and families who have experienced adverse childhood experiences, the fundamentals are similar to working in any family system I suppose is trying to understand the child in their context of not only their adversities but also the protective factors in their life and really importantly working with the child and their caregivers to try and do wraparound support to see what you can understand what the experiences may have led to some of the issues they're having also trying to work with the strengths of the family to see how we can make sense of what's happened and move forward. Great, thank you Nicola. I look forward to your presentation later this evening. And next is Dr Elizabeth Hone. Elizabeth, as a psychiatrist, can you tell us a little bit about how you differentiate trauma from other conditions that you might see such as attachment disorder, ADHD, autism or maybe other behavioural issues? Good evening Dan and everyone who's online. Thank you for having me. I think a really important part of trying to differentiate different conditions is taking a really good history and really understanding the background of what's happening for the child and the young person and the infant who present to you. I think the example story we're using tonight really demonstrates just how complex often issues are and they are in the background and I tend to kind of go by a bit of a mantra that says all behaviour has meaning and trying to understand the meaning behind the behaviour that we're seeing. I often kind of think of an iceberg with the behaviour being the bit that we can see that there's so much more underneath and in trying to take a good history, really trying to understand what's going on, and that's where we can start to really tease apart what the theological issues might be and also what's sort of underpinning the presentations and help with the differential diagnosis. That's really interesting. Thank you for that Elizabeth. We look forward to hearing your presentation later tonight. So before we go on I'd just like to introduce people to the webinar platform and so there is a chat box available tonight and then I'll chat amongst other health professionals in the audience and thank you to Jackie who's facilitating that for us tonight. And so through the night we will discuss resources particularly toward the end of the webinar which are kind of germane to the topic of tonight and we'll be able to share those with you. If you do have any technical issues please click the technical support FAQs tab for which you can get some help for technical issues. There is a number to call if you need further support and please I encourage you at the end of tonight to provide feedback at the webinar's conclusion by completing the feedback survey which is loaded under the survey tab at the top of the screen. So learning outcomes for tonight. For the webinar's completion we'd really like participants or participants to be able to define the key characteristics of adverse childhood experiences and we might call them ACEs throughout the course of tonight. We'd like them to be able to define the prevalence and their impact on children in Australia. We'd like participants to identify evidence-based effective coordinated practice for early intervention and prevention for children who have or are experiencing ACEs and to implement strategies to support parents and children to make sense of adversity in order to promote resilience and recovery. So what is an ACE? And obviously a definition of that is really important for both tonight's webinar but for the rest of the series that's happening over the next few weeks in this third stream of the conference. So an adverse childhood experience ACE is a potentially stressful or traumatic event experienced during childhood which can produce chronic or toxic stress responses in children that can persist through the live course. They can have potentially profound impact on later development of chronic diseases, mental health issues and problematic social functioning. The most widely recognized and researched ACEs include childhood physical, sexual and emotional abuse, physical neglect and emotional neglect, exposure to family violence, parental substance abuse, parental mental illness and parental separation or divorce and parental incarceration. So now what I'd like to do is hand you over to hear from our GP, Professor Kirsty Douglas in terms of working with ACEs from the GP's perspective. Kirsty, welcome again. Thanks very much. So I understand you've all seen the video link and I was asked to sort of comment on the GP's role in that respect and how that made me feel. And I guess, I mean, as a GP, you are very likely to be providing care to the parents, the foster parents as well as the key. And so part of your role is to provide a safe space for the parents to talk their fears and doubts and to be able to be heard because it's a really challenging job. It's about educating and linking to resources such as some of those ones that are available on emerging minds or the other child resources to provide parents with a greater understanding of what they're facing and what they might be facing. As a GP, obviously we care for people in-house but we often frequently need to refer to external support. And, you know, that's a critical issue is making sure that you know what your local resources are. Always we're also providing that basic medical care and we know that families under stress and children who have experience basis do have higher rates of all sorts of medical and psychological issues. And I think also importantly, you can, in your interactions with Steve himself, model a caring professional relationship that has clear boundaries and that might be relatively subtle and might occur over a long time but I think still can be quite helpful. And in terms of dealing with the foster family, it's about helping them with perspective. We're in this and teasing this for the long game and sometimes the more you read about ACEs the more challenged or depressed you can get. But, you know, most CPs are well aware that many people have challenging start but it's not everybody is swamped by it. And so a difficult start in life is not a diagnosis for despair and a difficult start when you've got supportive people around you that's involved in persisting foster parents and a caring and well linked caring team is much more positive. So I was then also asked to give my initial thoughts about the scenario as we saw it. And I mean, my first response is he's history in true safety. He really wouldn't be in foster care otherwise. In terms of my thoughts about the behaviour that he is exhibiting, that's who is very consistent with the child who has been exposed to ACEs. There appears to be some inappropriate affection at times and that is often an indicator of attachment issues which may well be present. And it may, she may have learned those ways of behaviour to keep safe when she was in an unsafe situation. And she may just be seeking reassurance but you also probably also have to have in the back of mind to be aware of sexualised behaviour as a potential indicator of previous sexual abuse. When I'm thinking about the sort of the outbursts and the periods of being disengaged, you know, that is probably or could potentially be her communicating her stress and distress through her behaviour. So I think in the first instance as a GP I would be wanting to acknowledge the challenges that the parents and family face and agree it's a really hard job. But also to recognise, celebrate and value their contributions to T's well-being for now and potentially into the future. And I'd be really supportive of them and reassuring that, you know, the evidence is that they can make a difference and they can make a big difference to T's prospects for a happy life from here on. As a GP, one of the big bits of advice I would say to other GPs is, you know, these are the families that you never try and see in 15 minutes. This family would automatically be on my book-along consultation list even if it's not asked for. It gives you and them the space to listen and be heard. We often need to and want to refer to psychologists or social workers in order to develop a supportive team that can wrap around this family. And one of the main things I try and think of then is stability in a team is going to be quite important. It's not always easy to achieve. But I, as a GP, tend to have a small group of trusted allied healthcare workers, psychologist, social workers that I know listen to me and who communicate with me and I make an effort to make sure I'm communicating well with them. And then it's the issue about being embedded in your local community and knowing your local resources. Sort of the resources that spring to mind that I might want to use with this family is potentially sort of looking at circular security training. If you can get in, it's not in the ACT where I work, it's very hard to access, but it is really valuable if you can. I would often be looking at referring this family to a child psychologist. And again, here where I work, there are often issues around affordability, but some access to people to resources for those that can't access it in private. And again, we have state-funded or territory-funded child and family centres which often have very good family resources that can be drawn on. They would be the first ones that I'm thinking about. If I was trying to give feedback to the family, particularly about initial help in responding to outbursts, as we were trying to unpack sort of longer-term plans, I would be encouraging the foster parents at those times of the outbursts to really try and provide consistent caring responses. Because that's probably what has been missing previously for T. And to reassure them that it's all right to set boundaries and to have explicit expectations. But it's really also important to try and avoid shaming T. And so getting that balance right between withholding of approval of inappropriate behaviour, but never withhold the care and concern about what's underlying that behaviour. And I'd be getting the foster parents to, while we were trying to get referrals and other supports in places, to reflect and observe on the experience of activities that they think seem to trigger T's disengaged or aggressive outbursts. Because that may well be important in understanding where she's most stressed and why she's likely to be stressed. And again, I would be encouraging the parents to really be vigilant at times when the she is affected with strangers because that is a time when she may be putting herself at risk. So we need to be aware of that and just encourage them to be extra vigilant. So that was really my sort of initial responses as a sort of clinician to that trigger. Thank you so much for that, Cassie. That was a really interesting and informative presentation and I look forward to asking you some questions about that later in the night. Our next presenter, as you've been introduced, is Nicola Palfrey. Before Nicola starts providing us a psychological perspective, just like to welcome those viewers that have just joined and let everyone know that we've got well over a thousand people tuning in at the moment. So again, thank you everyone for your interest in tonight's webinar. Nicola, over to you. Thanks, Dan. No pressure. Thank you, Dan. And thank you, Cassie. I think that was a fantastic presentation and hopefully think ways well into the psychological perspective that I'm going to try and provide this evening. So to start off with, I would say, receive a referral from Cassie to work with she and her family. The first place she would start really is what do we know already? And so from the limited information we already have, it's clear that she has experienced multiple ACEs in her short life. The information we've received has articulated that she's been living with carers or her birth family who had alcohol and drug dependence. And that almost inevitably, when it's really problematic, leads to a chaotic lifestyle. And that may not always be a defined ACE in a survey, but we do know that that is really something that can be problematic for children when they're trying to establish their sense of security and get their needs met when they're very young. The information refers to unsafe. Again, we don't really know what kind of unsafe that means, whether it's neglect or abuse. But however, just the fact that poor little people are living in a really unsafe situation, we know puts her in a really tricky situation for her trying to regulate herself and feel safe and connected with people. As Kirsty mentioned, you've been placed in foster care and really you can't be placed in foster care without having been exposed to multiple ACEs in your life. So from the brief description of Kirsty, you also mentioned around some of his behaviours and outbursts. There are maybe some suggestions that he may be experiencing or exhibiting signs of some type of attachment insecurity. Which is important and helpful sometimes in terms of how we might frame the work for the family. So there's a query, I suppose, that I've been holding in my head around certainly perhaps disorganised attachments. And what that means is that children such as he who have been exposed to this chaos and violence and real difficulty within their household really have struggled throughout their life to get their needs met consistently. So they don't have one particular way of being with their caregiver that means that they can be assured that they will be looked after. So they have to try different strategies. So even children that we know have insecure attachments have a strategy that works some of the time. So either they're staying very close to their caregiver and being not too far away from the nest to speak, get their needs met, other children who hide their needs and kind of seem very self-assured and resilient can get their needs met. And someone like she really has to try and try and try different things with the different adults who she's come in contact with to get her basic needs met. And so that means she's actually been very adaptive in that environment. She might be precocious sometimes or aggressive, overly friendly and those sorts of things and that obviously works at some time because attachment styles keep us alive. That's why we do them. However, the problem can be that we know that when you have those early experiences, those behaviors last longer than they need to. So even though she's now in a loving and caring foster family that doesn't need to behave in that way to get her needs met, it takes a little while for her to retrain and she will have to retrain her brain and her natural responses in order to try and see that she can get her needs met in different ways. So where do we start? I think sometimes it can feel overwhelming, parents or foster parents are coming in overwhelmed, see a distressed little girl and it can feel very difficult to know where to start. And I think starting with some basic understanding and communication of what we know about the impact of adversity on children without overwhelming families can be really helpful. Particularly for these parents and foster parents, we call them the parents they take care of her to meet her needs and understand why those early experiences are playing out in the way they are. So this disorganized attachment soul is trying in different strategies all the time. It's really also a reflection of our attachment soul which moulds our sense of self. Your internal working model, a lot of the viewers will understand that language, but it really is where I am in the world, how do I see myself? Am I a good little girl? Am I a bad child? What do I need to do in order to feel safe and secure? And so obviously when those have been saved by frightening early experiences, it's going to shape your approach to relationships. And as Kirstie has already mentioned, well, and Elizabeth has been an introduction that really we want to start thinking about what is the behaviour communicating because that's how we really need to frame what's going on for kids. Again, reinforcing it can't be underplayed that children that have experienced these early adversity and danger in life and end up with a style of disorganized attachment, perhaps are a greater risk of future abuse. So we need to really not underplay the need to be ensuring boundaries and protecting Tee and explicitly teaching her protective behaviour so she can be helped to keep herself safe. And that needs to be taught without shame. So this is something she needs to learn. It's not any fault of hers that she behaves in this way, but we need to be able to give her examples and support in appropriate boundaries. So some concepts that can be helpful in terms of working with the parents and helping them to feel less overwhelmed, I suppose, and with that sense of hope that Kirstie was talking about is the backhanded compliment. Now, what we mean by that is children that have had early experiences where connecting with adults or seeking support or comfort from adults has been dangerous or painful or downright over-fighting, kids are going to avoid that. They're not consciously, but when they start to get close to people and start to feel connected, like Tee will with her foster parents, she may reject that and reject it quite hard. And that can be extraordinarily painful emotionally for the adults. But really, when we see that, we know that we're getting somewhere which can seem counterproductive, but it is that if you've been hurt by getting close, then it makes sense that a child will push against that. It's really important about that repair of the relationship and coming back in as the adult to feel like it's actually a sign you're getting somewhere. But the adults will need support in that because it doesn't feel like you're getting somewhere. It actually feels like your whole world being turned upside down. And so, the next point, the parallel process, what's been going on with the Tee in her life is often mirrored in what's going on in the adult's life. So, the adults really need support. It's not just interaction with the child. You need to support the adults beyond the support Tee. And just a comment from the foster family that struck me was, she may be better off with another family. The mirroring how Tee may see her place in the world, that the parents are better off without her or she doesn't really belong. So, sometimes acknowledging that and talking about that can be helpful. Anger is a secondary emotion. It's a notion where a lot of people are familiar with that anger is the expressed emotion but what's behind it is often much more vulnerable emotions of fear or shame or sadness. And development versus chronological age. So, Tee at times could be operating exactly at her age level in terms of the months that she's been on this earth but other times she'll be behaving perhaps at a more regressed age because of the stress that she's been under and how we need to adapt to meet those needs. So, that can be helpful for families as well to understand that that's not a bad thing to meet the child where they're at. Finally, when you're working, as I said at the start, you'll be working not with Tee on her own. You'll be working with her foster parents and all of them in the room and sensory with Tee as well and really seeing how that plays depending on the specific aims of the therapy that you're doing. As Kirstie also mentioned, attachment-based frameworks such as Circle Security can be helpful even if you can't get into a full program utilizing the framework and the models behind it can be very helpful. Building a sense of competency between the foster parents and Tee to their lives together to build that connection and small opportunities for fun and getting to know each other in a light way when things are going well. Working alongside them to help them with it rather than intervening so you're the main character. You're actually just the conduit for the relationship between the parent and the child. Psycho-developmental psychotherapy by Dan Hughes has got some great examples of working with the children such as Tee. You can help them to put words for what's going on so not necessarily expecting her to come up with how she feels but providing some starters. Other children that I've worked with that have sometimes feel angry or other children find scared and working with her to help her put words for her experience. And yeah, finally always working with Kirstie said that this is a tough start in life but we've connected on going relationships and support each other. I think that's it. Thanks very much, Nicola. That was outstanding as usual. I'm really interested in some of that content particularly around the behaviours often lasting longer than they're adaptive so we might have a chance to talk to you about that later. I'd like to now welcome our third panelist for tonight Dr Elizabeth Hone who's going to provide us with a psychiatrist's perspective. So Elizabeth, welcome once again. Elizabeth, I think you might just be on mute there. Sorry, Dan. Yes, fixed now I think. Is that right? Yeah, that's better. Thank you. My apologies. I really wanted to take a perspective that took us perhaps to Kirstie and Nicola have really provided us with a lot of great thinking about collaborative practice working together as a really key issues in how we approach T and her family to support them psychologically and on a day-to-day basis. And I kind of wanted us to think a bit what was happening in the background to for T and really lend that perspective I think to the conversation. So to me a big part of my role as a psychiatrist and the work I do is to build resilience and to really my goal is to achieve social and emotional well-being and long-term physical and emotional health for the infants and children that I work with and building resilience and making that outweigh risk is a really key part of that that I'm aiming for. So the adverse childhood experiences or ACEs can contribute as we've seen to poor lifelong outcomes of mental health and beyond that. But the thing that we've got to remember with the hope sort of thing it's actually not the individual risk factors that might impinge on development that the most detrimental outcome we get is if we get this accumulation of multiple risk factors on a single child and that's the bit that we're trying to prevent. And we also know that if you get four or more of those risk factors then you're at significant risk just escalates exponentially. And that's what we're really looking at in T's case unfortunately she's been exposed to considerable adversity she's in foster care and certainly has had more than four risk factors. So what's happening for T in the background I like to think about what's happening at a brain development level. We know that that's genetically activated but it's also then directly influenced by social experiences and the child's environment and this is where she's really had a tricky start. We know the brain develops in a predictable, sequential, bottom up fashion and that we really want that sequence to be happening properly. We have simple systems and pathways that are developing first and then they get ever integrated into ever more complex ones. But it's actually the social experiences particularly in an interpersonal context that are impacting how this is going. We also know the brain changes enormously throughout life. We now know from a lot of older persons research that that plasticity is there throughout our lives that it's actually the rapid changes in the first three years of life that work to create our core brain architecture. And so we need to be thinking what's happened for T in this period of time. Her adverse experiences they may well have disrupted her healthy brain development particularly where there are sensitive areas of development such as language development her orbital frontal cortex which is involved in motivational behavior such as feeding, drinking particularly in relation to reward and punishment related behavior and therefore in how she controls herself emotionally and interacts socially. So we know from the brief information we have that T actually struggles to control her emotional distress at times and engages in inappropriate social interaction and therefore we can be thinking that it's very likely that she's got some of this damage and disruption to this sequential brain development has happened for her. And so we need to be kind of thinking about that as well as we're trying to work out how best to help her. One of the consequences of having this effective sequential brain development happening is that we develop self-regulation and executive functioning. These are brain control processes by which we learn to influence our emotional expression, manage complex tasks, stay focused empathize with others and understand the impact of our actions and modify them. As infants aren't born with these control processes they absolutely rely on their caregivers to regulate their internal physiological state. This is called co-regulation and it helps the infant develop a template for their own future self-regulation and it's what actually builds our resilience. So what happens when you have adverse experiences is that you actually impair the development of this self-regulation because you don't have enough of this co-regulation experience and that in itself then infects our executive functioning. We know from the examples the story that was given that T lacked a lot of these experiences. My guess is that she was far from having sufficient experiences of co-regulation from her biological parents and so we can expect that she's got compromised development at this point in time of her executive functioning and her capacity to self-regulate her emotions and behavior. This is important to kind of bear in mind when we're thinking about what might actually be happening for her, what diagnosis we might end up giving her because we need to hold in mind that she has this impairment of her regulation and executive functioning happening. She's presenting with social and emotional delays and she's struggling to safely use adults to soothe her emotional distress. So the other thing that kind of comes into play as Dan mentioned right back at the beginning is toxic stress. When the body's stress management system is activated there's an increase in heart rate, blood pressure, stress hormones in particular cortisol and proteins associated with inflammation are released into the bloodstream. These responses are all healthy responses when our body is stressed. They prepare us to deal with threat and they're essential for our survival in those circumstances of threat and that's fine if it's short-term and the threat is actually something that's very real to our survival. When a child's stress response systems are activated in an environment of supportive relationships with adults that co-regulation kicks in that we talked about and these physiological effects that happen in the body are then buffered by this interpersonal positive experience and are brought back down to baseline. The result is the development of a healthy stress response system. We know that stress can be positive tolerable or toxic. Positive stress is brief and mild while tolerable stress is serious but still temporary and in both of these cases the responses return to baseline when the threat is resolved and their impact is buffered by supportive relationships. So what about toxic stress? Toxic stress occurs when the stress response is extreme and long-lasting and we don't have those buffering relationships and co-regulation available for the child. Toxic stress can damage and weaken the brain's architecture and control systems. It can impact learning, emotional regulation, behavior and health. When it becomes chronic or is triggered by multiple health sources, it can have the accumulation of effect that I talked about earlier on an individual's physical and mental health and we now know that that can last throughout their life course. We know that T's experience toxic stress in her early years living with her biological parent. Therefore we can assume that that's impacted T's body, her brain development, her emotional regulation, her social interactions and her behavior. So how can we think about then going about repairing these ruptures to brain development to other aspects of her development and to help her build resilience now going forward because as the previous two presenters have spoken about, there is this hope that is so essential to maintain in all of this. So we know that positive outcomes for children in the face of adversity can be achieved if we have the ensure that there's a presence of positive and supportive relationships with caring adults that we support the child to develop a sense of mastery, control and self-efficacy because so much of that has been lacking in their lives so far. Helping them to create a coherent narrative for T and this is very much tied with language development and her experience and her lack of co-regulation she will have lacked this coherent story of who she is understanding herself her identity, who she belongs to and a lot of work needs to go into trying to help her to do that providing her with opportunities and support to repair and strengthen her weakened brain architecture scaffold her to build adaptive skills for self-regulation and executive functioning and as I said, maintain hope at all times. So for T a warm, positive, stable and committed relationship with her foster parents would be the single most important factor to reversing the damaging effects of the toxic stress and the adverse experiences she's had and will from there help her develop the resilience that will take her forward on a much more positive trajectory. So thanks Dan. Thanks so much Elizabeth. That was a really great presentation and lots of questions coming from the chat room and so maybe we might start with a question for you if that's okay and I know that throughout your presentation you talked about the fact that brain plasticity is ongoing throughout the course of the lifetime which kind of corresponds with the question that Robert has asked which is that T is not on some of those key developmental regulations of an early age but does that mean that she's missed a boat in terms of being able to recover from that or is there a way that we can work with T to kind of make sure that she's able to recover from the boat? I think we can we know that we can recover a lot of that functioning I think there's this kind of graph that you can think of in three years of life the brain is absolutely wired to develop its architecture and so everything happens almost on autopilot and very quickly and efficiently from there on as you move through life recovery still happens changes happen in the brain all the time and we can build new pathways all the time but everything takes longer and it's slightly harder because it doesn't work as quickly and as efficiently what we know is that what will happen is with her new experience with her foster parents if that's a positive experience and is predictable and consistent and stable that she will then develop a new pathway next to that old pathway that those old pathways that she's developed and the more that happens the stronger that new pathway will become and then as that new pathway becomes stronger the brain will start to prune out the older less efficient pathways the damaged pathways and the ones that she then no longer needs but that's going to take time unfortunately we do know from the research that there are some sensitive periods of development that need a lot more work and may not entirely recover but I think the really important thing is the more that she has this positive relationship the better that's going to be in terms of her future and she's still quite young at this point in time the thing is we don't know when she was brought into foster care so that's at the moment probably a fairly hard question for me to be really specific about we know that ideally you'd want to be removed from your parents of situation and come into care before 24 months because of how the orbital frontal cortex and some of those parts of the brain that are highly dependent on positive relationships develop Thanks for that Elizabeth Kirstie I might go to you next because we do have quite a lot of interest in this area on this particular question and from your perspective can you talk to us a little bit about what aspects are from ACEs and are these manageable in later childhood or in adolescence in adulthood Yeah sure, well I went look there the long term clearly are significant and diverse and you know in my daily practice it can be greater instances of depression greater instances of dysfunctional relationships abnormal eating behaviors higher incidents of diabetes heart disease is really very diverse and again it's you know as a GP we treat the person not the disease and so it's about developing a long term mutually respectful relationship and working with an individual about what is their priority now and how can we support them and move them forward and so sometimes you will work with somebody who's got depression and really is just wanting to be very forward thinking and move forward from now but then later on they'll develop something else and you know I've certainly worked with adults for many months it's not years before you're comfortable disclosing adverse childhood experiences and then wanting to think about how that might have affected where they're at at the moment so the effects are very widespread I've found the more you ask the more you find and it's really then do you have to unpack them all for everybody? No I don't think so sometimes it's part of a history and it's acknowledged and they want to move forward that other times it's something that they haven't really dealt with and it's had an insidious effect that they have maybe not been aware of and it can be very helpful to then go back and address it so it is variable and sometimes you refer to psychological support early and sometimes not wanted at all Yeah thanks Kirstie I might just ask another question from that as well so if we take tears a case example are there preventative practices given the ACUs that she has been through that we can apply in our work with her which you think would have a good chance of ensuring that later social effects aren't as serious or as negative? Well I mean I think Elizabeth has already covered, Elizabeth and Nicola have already covered them, I mean it's not possible if we can encourage sort of supportive ongoing relationship in a stable environment that has wraparound support so that she is laying down those more adaptive behaviors and more functional and efficient neural pathways then that is the ideal but also I think being you know I think for me that's one of the joys of general practice is that you often have a long term relationship and you can see people evolve over many many years and it's not like you need to have having an awareness of adverse child experiences doesn't have to penetrate every single consultation but it's always helpful to know in the back of your mind because it may make you think of slightly different ways of approaching things. I was thinking just recently I was asked to see a woman who I hadn't seen before but had been a long term patient of the practice and she just wanted to do a routine tap smear but when I was doing the routine tap smear which was very technically easy to do she was obviously quite distressed but I've only met her once before and so just as I was writing the labels I said look I hope you don't mind me asking but I noticed when I was doing the tap smear that you found it very difficult and sometimes that can occur for people who experienced previous abuse in their childhood do you want is that something you'd like to talk about and she just looked at me and she said no, no not at all and then as I was finishing writing the label she said well yes but I don't want to talk about it I said fine but just if you ever do then I'm happy to discuss it with you now she continued to see other doctors at the practice for another six twelve months and then came to see me again with another physical health problem but at the end she said you might want to see a psychologist about what happened in the past so I think you need to be open you need to be working at the pace that the patient is comfortable with work at and you know that's obviously very different for children versus adults but I think having that understanding of that in the past can help you be more proactive and take if you like secondary prevention approaches in all of the diversity of the medical care you're providing yeah thanks Kirsty so Nicola what are actually your question now because we're getting lots of questions really through the chat room just in terms of this idea of backhanded compliments and just wondering if you could extend upon your explanation of that sure so the backhanded compliment is a term that I came across when we were looking at and kind of talking about the experiences that a lot of caregivers have particularly foster carers who have foster children in their care come into their home and things going really well could also be any teachers trying to engage with children things are going really well and that child may have been difficult to engage or being resistant or yeah just taking a little while to make the connection and things seem to be going really well and in foster care they often talk about the honeymoon period so a child comes into your care and that honeymoon period where everything is smooth and great and wonderful could last anything from six hours to six months but almost inevitably it kind of comes to an end not forever but in terms of an escalation often a kind of big blow up and often a very big blow up and by that I mean so some kind of argument or fracture between the child and the adult and in that often children particularly those who have had significant adversity can really push a button in their caregiver they kind of know how to hurt them and so you have this real rupture in the relationship where things have been going along and the adults have been trying and trying and doing everything according to the textbook to connect with the child in a safe and secure and stable relationship and it gets thrown back in their face and so what we mean by the backhand of compliment is that we would see that as things, you're doing the right things so what is happening is you've gotten close and close and close and the child is being responding to that in socials then all of a sudden they've hit their limit and they're unable to cope with it anymore and it's triggered in then usually an unconscious unintentional explosion something has triggered a fear response in them and they have lashed out against that and rejected that caregiving and that's the backhand compliment is that you're getting someone you're getting close but unfortunately at that moment the child can't tolerate it and so in that circumstance we talk about the need to support the adult happens in therapy when you're working with a client and all of a sudden they lose it with you and start screaming at you or storm out or you know do say something really mean that's the backhand of compliment well often if and so the adults that experience it need support because it hurts because they're human as well but also support to go back in between the children because they have a responsibility for the relationship and just is important if not more important is the repair they're going back into the child and not in that moment the next day or the day after talking about what happened reassuring them that they're not going to be rejected or that's not going to be the end of the relationship but we're going to work about how we can move on to that or understand or prevent that from happening in the future so that's what we mean by that backhand of compliment Thanks Nicola and while we're talking to you and we have a really great question from Kieran who's asked to you that you mentioned that psychotherapy might be a really good therapy for a team to help her to put word share experience so in light of this Kieran's just wondering what might be some of the theoretical orientation she's taking about? So in terms of how we might work in a therapeutic relationship with me she's only little, yeah? Psychochemistry? Yeah 6 Yeah I think in terms of how therapeutically you would work with T would always be in relation to her foster parents so you're not just going to take T off on her own and work with her with no regard for the relationship between the caregivers because as we've all talked about tonight that is going to be the most restorative thing and protective thing for T in the long term so working with T and her foster parents around their goals what are their primary objectives and so you might work in an attachment based framework where you're looking at the roles and responsibilities in the household the role of communication how that is playing out in behaviour and working together with T and her parents to look at how that can be developed in an ongoing way and have some experiences of success of meeting needs and understanding that's why the circle of security can be really helpful that's kind of mapping of where she may be and what her needs may be because she's got some pretty ingenious ways of understanding her needs or expressing her need in a way which makes it hard for caregivers to respond to it well and so I think the theoretical model I don't tend to work on one specific way which can be frustrating for people to listen to me I suppose but I suppose it's informed by an understanding of the impacts of trauma and adversity on children informed by an attachment theory and informed by what the family want to do with play therapy or narrative therapy with T for a drawing and R for those sorts of means as well but also really the relational thing which is what I'll be working with most in terms of scaffolding and supporting the relationship between T and her for the parents and I hope that answers the question Elizabeth a question from you for one of our registrations is asked that in children can often result in long term anxiety and do you agree that anxiety needs to be looked after professionally and kind of nipped in the bar so that children can discern the anxious feelings of children when they encounter other I think my answer to that would be yes and no I think there's as we've already seen tonight with Kirsty's comments there's a real role for professional help but the key remains I mean professionals only see people for short bursts so the key remains that the foster parents are the ones that can do so much to help reduce this anxiety to support T and children like T get that anxiety under control and that really is a number of different things it's staying with the child when they have their emotional outbursts when they lose it just waiting for that to calm down a lot of good parents do this intuitively and so we would hope that her foster parents can be predictable and consistent enough and it is not a perfect situation but to do it enough of the time to be able to just sit with her and let her know that someone can actually sit through this with her and if she starts to learn that she's not alone in this anxiety she's going to start having that experience of co-regulation that she didn't have with her biological parents at the beginning and this is something that we do need to she needs to re-experience this in a new way and learn that she can sit with this that her anxiety is not going to overwhelm her and that they can then help her to find ways of managing this and coping with it so I like to kind of think of the fact that there are kind of two important components to that the first is this being with or being able to calm down the anxiety so we know that it's actually the amygdala in our brain so to speak in our brain it is the thing that registers our fear and it's the thing that then sparks off our fear response and makes us feel this anxiety so we actually need to calm this part of our brain down and we know there are two really really good ways of doing that very quickly one is to be able to effectively use relationships to do that and to be able to do that she needs to have this experience of co-regulation often enough to be able to trust that and when she came into care she probably didn't have that capacity at all because she hadn't had enough of that experience and so as both Kirsty and Nicola have said this takes time of this consistent caring relationship for her to be able to trust that this can happen and to be able to use adults to calm down the other way of calming down which we often as adults can use so kind of do mindfulness type activities, relaxation type activities, deep breathing so for a 6 year old even simple yoga exercises there are apps online like cosmic kids those sorts of things can be really helpful using meditation type music guided imagery music all of which you can get in apps all of these things are other ways that you can help teaching them to blow bubbles through straws to actually learn to control their breathing being able to breathe in and out for as long as the feather floats down there are lots of practical strategies to kind of build that part of their brain so once you've done that sort of training and learning to calm down being able to use foster parents and other adults to do that the other key activity that foster parents need to do is to help her build alternate strategies help her to develop coping skills to be able to say that didn't work so well last time I wonder how we could do that differently or I wonder what else you could do to be curious about alternative types of behaviors because that's actually what helps her build new pathways to better executive functioning but those sorts of things can happen in that day to day moment by moment thing and that's the crucial part there is a place for professionals to scaffold that and support that but it's actually the foster parents and the day to day everyday experiences that will really reinforce that and build that thanks so much for that Elizabeth our next question is from Alice who's asked about the content that Kirsty and Nicola were talking about shame and how to avoid shame so maybe Kirsty can start and then Nicola you might add to add something how do you avoid shame when working with particularly parents so that they don't feel constantly that they've just done the wrong thing but at the same time that they can get better at how they're providing support for their children's mental health and social emotion I think about often very much listening to begin with and trying to understand their perspectives and their motivations and their reasons for doing what they've been doing and what they're trying to achieve by doing so I think listening is critical and then trying to reflect that back but also potentially make suggestions around why trying something else might be valuable and I think underpinning this is a respectful and honest relationship and you don't different DPs work effectively with different families and often over time families and DPs end up with the patient that sits in both and the same with other health professionals I'm sure I think making to avoid shame you have to listen you have to build a relationship on mutual respect and being honest but reflective and I think that if you've got a non-judgmental and interested and curious and people feel that you really have them and their children's best interest at heart then I think you can have some really challenging conversations and still manage to move forward I think if people feel that you are delivering judgments or advice without with some sort of theoretical background without but without effectively contextualizing it or putting it in the context of their lived experience then that's when people feel shamed and feel turned off I mean that's like my approach but I'm sure Nicola's got some other thoughts Thanks Kirstie, yeah Nicola do you have some thoughts on that? Al Kirstie said a lot of what I was going to say which I suppose is good I think yeah absolutely I think that the relationship that you have with the families you're working with is critical for that and there needs to be a lot of work going into that relationship and taking time to understand the adults in their child's life and their perspective and listening to them and what their hopes are and what their challenges are is it critical to be able to work honestly with them and be able to reassure them that you view them as doing the best that they possibly can and that you're going to work together to improve that but no one is expecting perfection and that just by them engaging with you is making it very clear that they're keen to do better so I think that is a start but I think it's also important to recognise that you can't sometimes you can't help but evoke shame if you don't want to particularly if you're working with parents around parenting and if those adults themselves have experienced trauma diversity we all go to shame at sometimes we feel judged even if the person delivering what they're saying isn't intending to do that so I think it is important to note that you can't help but sometimes evoke shame in others and it's important to acknowledge that and talk about that with the family and I think one of the most helpful ways is again the parallel process so working with the families around their experiences and how they experience emotions and how they feel about certain events so what goes on for them when they experience these outbursts or provocative behaviour and understanding for them what's going on with them and I think if you're having those rounded conversations about them and their feelings and how all of us have them at times and they can become overwhelming even shame at times and that can lead into the conversation if you can name it about how helpful or otherwise that is and if we are evoking it then what are we doing and we have to look at our own facts and thinking because when people are sitting in shame they can't take on new information and they certainly aren't going to be able to do the best for themselves because we've put them in a state that shuts that down. Thank you Nicola and once again thanks to all of the wonderful questions that are coming through the chat room I feel like it would be great to sit here for another hour and continue to ask our panel of questions but we are coming to the end of our discussion so what I'm going to do now is to invite each of our panelists to just add a final summary or final observation from tonight's topic so I might start with you Kirstie if that's okay Yeah I mean I guess my final observation is they're incredibly important they're unfortunately very prevalent and they have very diverse effects I mean ACEs on children so I think being aware of them asking about them and being prepared to work in the long term with families and children affected by them is a really valuable contribution you can make to somebody long term health and well being. Thank you Kirstie and Nicola would you like to add some final comments? Yeah I think we've built on what Kirstie said one thing we haven't necessarily talked about a lot tonight is some of the concern about ACEs and the kind of ACEs movement or people talking about asking people about their early experiences and the concern is that it can be seen just as another way another sick to beat parents with or another kind of diagnostic label to throw on children and I think it's really important as we've been talking about tonight the only use they can be is if they're used in relation to the whole child and understanding of what they've been through and putting that in with all the other evidence and information and relational context that you have so we would never advocate just asking around ACEs to get a number and not to do anything with it rather than a sheet of paper it needs to inform what you're doing to make however you're working with a family more effective yeah thanks and Elizabeth your final thoughts just thinking for me it's really there are three key things one is about relationship and it's always about relationship and building that relationship with families at every level and also between us as a group of practitioners working together to support the families as Kirsty said right at the beginning having really good ways of communicating with each other it's about building skills we need to rebuild when we've been exposed to all these ACEs it's really about rebuilding a sense of self-efficacy and mastery of the world because so often you don't have any sense of control that will then help you feel so much better about yourself and about your ability to move through life and the third key area I think to think about is the fact that we really are trying to work about building something different internally something that's not built on judgment preconception but really something that's changing how the child, the adult the family are feeling internally about their personal experiences and who they are and really building that sense of identity and belonging and making that the really strong thing because if you have a strong sense of identity and belonging then you're going to be resilient and be able to weather whatever life brings to you much better than otherwise so I think the really key thing that I want to kind of finish on is that connection is ultimately important and we often hear people sort of saying oh they're just attention seeking but I'd really like to kind of leave us with the thought at the end that they're not attention seeking but in fact connection seeking and we have a role to kind of make sure that happens and really support building that connection so thank you. Thank you Elizabeth and thank you once again to all our panelists tonight I think you'll agree that the presentations in the Q&A session has been okay so we're getting close obviously to the end of tonight's receding so again thank you to the over 1000 of you who've joined in tonight that's been fantastic just for your information other supporting resources associated with this webinar can now be found in the supporting resources tab at the bottom of this screen for more information about Emerging Minds please visit our website at www.emergingminds.com.au or for MHPN this particular conference visit www.mhpnconference.org.au remember in this part of the conference we've got some really exciting online webinars coming up on the 30th of May for example we've got two sessions one with our child and family partners during the day and the other with some practitioners who will respond to our child family partner and of course please don't miss the other half of this webinar which is on the 6th of June at 7.15pm eastern standard time and that's talking about working with parents who have experienced that child experience so we're really looking forward to bringing you that in a couple of weeks so again thanks for participating please can you make sure that you click the feedback survey tab at the top of the screen to open and complete your survey we'd love to know what you thought of tonight and what we're doing well but also what we could do to improve what we provide for you a certificate of attendance will be issued for you as part of this webinar and will be available for you within six weeks each participant will be sent a link to the recording of this webinar and associated online with resources within four weeks and please again visit www.mhpnconference.org.ie for details on the upcoming webinar as part of the trauma of this child experience as part of this online conference so this webinar was co-produced by MHPN and Emerging Minds for the Emerging Minds National Workforce Centre for Child Mental Health Project and Emerging Minds that is delivered in partnership with the Australian Institute of Family Studies the Australian National University the Parenting Research Centre and the Royal Australian College of Junior Practitioners the project is funded by the Australian Government Department of Health under the National Support for Child and Youth Mental Health Program MHPN supports the engagement and ongoing maintenance of practitioner networks where clinicians from different disciplines meet regularly with other mental health practitioners and they'd like to invite you to continue to learn about what happens as part of this network through mhpn.org.au Before I close I'd just like to acknowledge the consumers and carers who've lived with mental illness in the past and those who continue to live with mental illness in the present. Thank you to everyone for participating in this evening and we really look forward to meeting you again soon.