 Hello and welcome everybody to what is the last webinar in our MHP and Emerging Minds online conference stream which we've been bringing to you over the last couple of weeks and tonight we're going to explore the impacts of adverse childhood experiences or ACEs as we might call them on parents. So welcome to the well over 300 of you who are currently logged in and to those of you who will be watching us through the podcast, welcome. This as I said is the conclusion of the online conference stream on trauma which Emerging Minds and MHPN have collaboratively produced and it's been a lot of fun joining with you over the last couple of weeks. So as I said tonight we're going to look at parents who experience adverse childhood experiences or what we might call ACEs. Before we start as usual Emerging Minds and MHPN would like to acknowledge the traditional custodians of the land across Australia upon which our webinar presenters and participants are located. We wish to pay respects to the elders past present and future for the memories, the traditions, the culture and hopes of Indigenous Australians. This webinar is a final activity in the trauma the impact of adverse childhood experiences context stream in MHPN's online conference, Working Better Together. So my name's Dan Miles and I'm the Workforce Development Manager at Emerging Minds and it's been a great privilege and pleasure to be joining you for a number of webinars throughout the year and we've had a lot of fun being able to bring those to you. So I'd like to present you with tonight's panel before we go any further. First off I'd like to introduce Courtney Sherman. Now Courtney is a social worker who currently is at Emerging Minds but has had much experience working with parents and children. So Courtney I wonder if you could start off telling us a little bit about how as a social worker you've worked in parent-sensitive ways for adults who have experienced ACEs while still maintaining a focus on working with them. Hi Dan and hi everyone that's listening. I suppose it can be quite tricky doing the question that you've just asked. Often when you're working with families with complex trauma and who have experienced ACEs you have a lot of multiple and sometimes competing demands. I think first off we really need to partner with the parents and make sure that they feel supported by us. One of the things that I've always done within my practice is make sure that child development and child well-being is discussed from the start. The earliest possible conversation we can have with the parents about their child's well-being is obviously going to be the best because when we need to start raising issues of concerns, risks or issues it's not as daunting or as threatening. We're able to offer support and it becomes a normal part of our interaction. The other thing is we know that some adult issues can dominate interactions and overtake the conversation when we're working with families. We're always trying to link it back to the impact on the child and their well-being. I think if we can do that it really starts to support families. Great. Thank you Courtney. I really look forward to talking with you more tonight. Our next panelist is Dr Mary Salver and many of you will know Mary through her research work but also Mary's work as a psychologist and Mary I wonder whether you could tell us a little bit about your breadth of experience including working with parents who have experienced ACEs and are involved with the statutory child protection system. Sure. Thanks Dan. I've been a researcher for over 10 years at the University of South Australia. In terms of child protection and in that time I've been involved in undertaking research and evaluations of child protection programs, policies and practices. My PhD research specifically examines the experiences of parents involved with statutory child protection involvement and specifically I wanted to understand what facilitated and inhibited parents involved, what helped them visit their children who had been removed because the child abuse and neglect and the factors that inhibited them from doing that. And the parents, the removal of their children and their placement in care resulted in identity trauma given the complete disturbance of their sense of self and contributed to the biasing that parents endured and I hope I'll be able to explain this a little bit more in my talk. But I was also co-chairperson of the Family Inclusion Network of South Australia and that was comprised of parents involved with statutory child protection. Some were able to navigate the system and have their children return, create the change and have their children return safely and some had their children in long-term care. There were also practitioners involved and staff, academics, practitioners from government and non-government agencies. But that grew aimed to support parents and families, participate equally and respectfully in the child protection process. Parents felt very tolerant. They didn't understand what was this child abuse and neglect because this was better than the environments that they had grown up in. So it was about them learning the new parentalised and the system and others wanted them to change to. So that particular group was about advocating for parents, what their rights were, supporting them with information and access to legal services. So supporting them with teaching them about attachment, teaching them about the system, what was the expectations of the system. So really walking them through the change that we wanted to see for themselves and their children. Thanks so much, Mary. Our final presenter tonight, some of you would have heard from our previous, some of our previous webinars, Professor Nick Calenco. And Nick, in psychiatry, tell us a little bit about what you're mindful of when working with parents who have experienced ACEs. Hello, Dan. Hello, everyone. Well, I think a lot of issues, which Mary touched upon, but there are probably a few crucial issues working with parents who have experienced ACEs. And that's often that there's an experience either of shame or concern. Well, I guess as Mary was alluding to that, I might have some distorted ideas about parenting and what's good for kids. But even with all of that, they're usually quite committed to wanting the best for their children. So that's kind of a platform on which, if they also suffer mental health problems, then also makes them really a lot more sensitive. But I think the issue Mary raised about that sense, the core sense to identity provided by parenting is always an avenue for talking to parents about the significance. And they invariably value it. They invariably keep it in front of their mind. But there's often a lot of barriers to talking about. So often I sort of start with questions about, you know, what got you through in the experience of the parenting you had when you were growing up? What gets your children through now? And you can, that often will get people at least to start off and going, and you get a sense of their strengths. And you can always ask about the kids, get them to tell you about the development of their children and make them, in a sense, the experts. So these are the kind of ice breakers, I think, to getting into issues about their experiences of parenting and potentially the impact of adverse child experiences that they also experience. Thanks so much for that, Nick. And definitely looking forward to hearing more of your presentation later on this evening. Thank you. Oh, I should just mention Dan. He's a professor that I made a spy to me. So I'm Dr. Nick Collick. Yes, we're good. Yeah, I'm not sure whether that's a promotion or not. We'll take it. Apologies. Yeah, yeah. Okay, so let's just think a little bit about the webinar platform that we have for you tonight. So we have Valeria and Josh on our chat box who are taking some questions. So this chat room is this gel chat amongst other health professionals in the audience. We will discuss resources that you might like to consume later in the webinar. If you do need some technical support, there's a technical support FAQs tab at the top of your screen. Now at the end of the night, we're going to ask you to fill out a feedback form. And by cleaning the feedback survey which is loaded under the survey tab at the bottom of the screen. So we'd really appreciate it if you could start to kind of help us get better at what we want to provide for you. So tonight we've got some learning outcomes. And so the webinar is pleasing. What we'd really want you to be able to do is better understand how the long-term effects of APE impact on adults and their pain and the therapeutic patients that help overcome these impacts. We want to be able to implement two strategies for adults and parents to make meaning of their APE and to ensure a practitioner focus in children's personal emotional well-being when working with parents who are being affected by APE. So what is an APE? So talking tonight will be a lot around our first childhood experience. What we're really meaning is a potentially stressful or traumatic event, experience during childhood, which can produce chronic or toxic stress in children that persist throughout the life course. They can have potentially profound impact on the latent development of chronic diseases, mental health issues, or problems of their children. So the most why they recognise and research APEs are childhood physical tests on the emotional, physical and emotional traits, exposure to family violence, parental substance abuse, parental illness, mental separation of divorce, and parental illness. Okay, so tonight our presenters will be guiding you through our case study. So you might not remember those of you who tuned in to our APE presentation on working with children. We worked with APE, who at the time was six years old and was now in care. For tonight's presentation, we want to go back three years. We want to be working with T's parents, birth parents, which is still in the household, and seeing what prevented his early intervention conversations that we might be able to have with T's parents, which he was three, and he's going to accept it. So now, I'm going to ask Courtney to talk about that from a social worker's perspective. Courtney. Okay, thanks, Stan. So I'm going to present, I've got three slides. And before I present the slides, I just want to make sure that these aren't meant to be in a fixed linear process. It's something that would consistently happen through a case plan intervention, but it's just the way it's set out for the webinar. So first off, my first slide is about engagement. And I don't think that we can stress this more. Our ability to engage with the family and be really respectful and empathetic during our engagement is something that we really need to concentrate on. Now, we know from practice wisdom, but we also know from evidence that families that come from history with child protection, out of home care, trauma, abuse, and neglect, they can be very untrusting of the service system. So we really need to be transparent and really actively listen. The other interesting complexity with this case is something that we really need to acknowledge is that these two parents were children of the child protective system until very recently, and now that's changed into now they're the parents. So that's something that I'd be quite conscious of and seeing what complexities can come from that, additional complexities. The other thing is to make sure that we meet the family where they're at. We can come in as social workers and professionals and have a thousand goals of where we want this family to be, but that's not where they want to be and they might not be ready for that change. So we need to really listen to what their hopes, their fears, and their aspirations to themselves but also their children are. And most importantly, we shouldn't be setting them up to fail. We know that families with trauma, ACEs, and a range of other issues need some additional support or so might not be functioning to the level that is expected, I suppose, of them. And now the next slide that we have that I have is assessment and I'm not talking about a diagnostic assessment here. I'm talking about trying to find as much information as we can about the family in a quieter, supportive, and therapeutic way. And I've put two things up on the screen now as one is the genogram and the other one is an eco-map. And these are something that I use in my practice all the time. I find that genograms can be a really therapeutic process and it can allow the client to have a visual representation of their family, where they've come from, where they are now and where they want to be. It's also an opportunity to allow clients to perhaps lift or shed some shame of and to see their family circumstances so they can see the intergenerational trauma. They can see ACEs and relationship disruptions and they might be able to see patterns where they want to really work on those areas so it's not the same for their child. Now, if I had the opportunity I would really get team involved with this. And when I do genocidal families, it's something that I really want to make fun so I really want to be able to kind of hop on the ground with them, get the pen out, get the text out and make it a really collaborative experience. So if I could get team involved in that that would be something that I would really be striving to do. If not, this would be a place to really ask some of those explorative questions about maybe perhaps the Justin of, what was it like with your mum before your stepfather came along? What are your hopes for tea? What was it like for you as a child? And this can be done in quite a trauma-informed way as you're not sitting across from the family with a notebook. You're sitting side by side so you're kind of, you partner with them in an activity. The other thing that I really use is e-comaps and I find this is really important and it can help the family kind of see what their social supports are, what they have in the community if they're in formal or formal support but it might also help them see that maybe they've only got friends that are involved in substance misuse. Do they have supportive friends or supportive families that they can draw on for parenting advice perhaps? The other thing is, what connection does tea have to the communities? We know that children that are connected to the community have a sense of stability but also what does she need to be able to... What would support her with her social and emotional well-being? So is she connected with her peer group? Does she go to a childcare? Does she go to a play group? I find that by having these drawn out it can really support families with that. And my last slide is some of the approaches that I would use. Now, these aren't the only approaches that I would use but these are definitely the ones that come to mind. So we have a family with high levels of trauma, high levels of ACEs, so being trauma-reinformed and being trauma-reinformed is something that I would do with all families, not just the ones that we know come from a trauma background. I also think it's really important that you don't actually need to know what the trauma is to work this way and it's not about going on a dig to find out because that can be quite triggering to families. What we also know is we've received a substantial bit of information in the referral with regards to their background but that might not be all. There could be some quiet... There could be things that the parents aren't telling us. There could be things that have happened but maybe they're too ashamed to talk about it so we always need to approach it with we don't know everything. The other approach is motivational interviewing. Now, this is something that I've primarily done where I'd use with Justin. I need to find out a little bit more about Janet's ID and what her functioning is so it might be to really kind of use the motivational interviewing with Justin as he has more of a reflective capacity and see if we can get Janet doing some more practical tasks of parenting. Now, the last one is child development and I've put chronological verse developmental age so we know when we have families that have had extensive amount of trauma their chronological age doesn't actually match their developmental age. I think this is really important as I would be surprised if T is developmentally three but I'd also be very surprised if the parents were developmentally 17 as we know that the history that they've had. So what approaches do we need to use as professionals to adapt our language and style to support the parents to understand what we're talking about but also to support them with their child and her development? Justin's mentioned a couple of things in the case study that he really enjoys having T around but doesn't enjoy the crime. So what does that mean? How can we get Justin to understand that perhaps T's crime is her only way of communicating because she doesn't have the language? So really focusing on what it means how children develop. Janet said that she really loves T so building on that. What else do children need to really support their development? Loves one but what else can we work with that? To really harvest in the strengths. That's my last slide for the moment so I'll hand it back to you Dan. Thanks so much Courtney and I have to say that is one of the most impressive genograms of the time. I think it's during the game of thrones which is very topical. I do like it detailed. Just to let people know that apparently we've had some feedback that we do we have had a couple of sound issues and we're endeavouring to get to the bottom of those so hopefully that improves really soon. Okay I'm now going to invite Dr Mary Silver on to talk us through the case study from the psychologist's perspective. Thanks Dan. So we know from research that adverse childhood experiences have lifelong impacts and consequences. So ultimately you see it on the screen it impacts on those who have experienced high risk of experiencing psychological disorders personality disorders, addictive disorders, social isolation, poor learning and employment outcomes and in addition they're more likely to develop heart disease, stroke, cancer diabetes and so on and more likely to die of suicide. Ultimately how one views themselves, how one manages their stress, how they manage their emotions, how one learns, how one reflects and how one interacts with others. These are the long-term impacts of adverse childhood experiences. So we know that the therapeutic alliance is vital so the approach of stance that I would take would be a compassionate, empathic and non-blaming one focused on establishing rapport and trust with Janet and Justin. So this means providing a safe place to listen actively to their stories being open with them in order to understand the world through their eyes. Both have experienced significant and cumulative traumas over their lives from abuse from Justin's stepdad to multiple placements for Janet since her own childhood. Because of what we know about the impact of ACEs I'm aware that Janet and Justin may view the world in a certain way, one that's uncertain and unpredictable. Perhaps negative and pessimistic that they may be guided and not as trusting. So I imagine Janet and Justin may be overwhelmed by confusing facts, current and potential problems and necessary decisions to be made. So by offering them assistance in deciding what issues to be faced first and problems that need solving now we can begin alleviating some of that distress. Work with Janet and Justin will aim to build their personal resources, their strengths, understanding their family ecology with the aim of building their autonomy and responsibility, motivating them that they have choices, that they can take control and they have the power to create change. I want to stress here that while parent worker engagement is critical, I need to highlight that engagement is necessary, but it is not enough for children's safety. Ultimately, if we think to change for T, there need to be changes in Janet and Justin's behaviour that acknowledge and meet T's needs as a three-year-old who is dependent on her parents for survival. T's safety is priority here and the current information we have about Janet and Justin suggests they're struggling to look after T. If we find that Janet's metamphetamine use is very frequent and severe and T's needs are not being met, support from a medical withdrawal service or even more optimal is a community residential treatment where Janet can be supported to get treatment with T, which can focus on repairing the bond between them and supporting their physical and mental health into personal and social skills and T's development. And supporting T's relationship with Dad Justin which means as Courtney alluded to before, unpacking what Justin means when he says he likes having T around but he doesn't have energy to put up with a constant crying. Does he have fears about being a dad? What a day. Again, modelling, showing, demonstrating what conversations and interactions could look like with the three-year-old would be key. Talking about the routine she needs, that she copies and imitates, she engages and pretend play, she can follow simple instructions and she sees and is trying to make sense of the world. Cases like Justin and Janet's are complex and require an intensive long-term view of support involving a multi-D team. What I'd like to focus over the next few slides is on case conceptualisation of Justin and Janet's situation. So case conceptualisation is a way of organising the information gathered for developing the story that explains the underlying mechanism of Janet and Justin's presenting problems. The conceptualisation is collaborative, which means it is done with Janet and Justin and it's dynamic, which means it's that new information comes on hand, formulation is reviewed, added to and changed. So case formulation puts seven P's into context. What is Janet and Justin's presenting problem? What is the pattern and onset? What predisposed them to the problem? What precipitated or triggered the problem? What perpetuated the problem? What are the protective factors and what's the prognosis? I would acknowledge to Janet and Justin that they are the expert at their lives. They know what's going on and that my knowledge is about how problems start and how problems keep going. And together we can come to understand the problems and put to practice the different strategies to overcome them. Case conceptualisation is really important because it provides an overall picture of Janet and Justin's situation. It helps clarify questions that I might have. It helps prioritise issues and problems. It helps plan treatment and strategies. It can even predict responses to interventions and identify barriers to progress. So for Janet and Justin, the presenting problem here, maybe Janet's methamphetamine is Janet's methamphetamine use on parenting T and not meeting her developmental needs. I would seek to find how do Janet and Justin understand from their perspective what the problem is. I would seek to understand the pattern and onset of the problem. Did the drug taking start only recently after a crisis? The third point, predisposing factors are those that make Janet and Justin more likely to behave in a particular way and this would come from their histories and past experiences. The precipitating factors are about the events leading up to the crisis, which may come from different forces. Are there ways that the trajectory could be changed to prevent drug taking? In this case, many factors could be maintaining the problem. Finding out from Janet about the role or the function of methamphetamines, for example, is it to alleviate or escape the intense pain of abandonment, loss and rejection she has endured over the last 20 years. We may be able to learn about the hurtful and negative things that Janet tells herself, which influences the way she feels about herself and the behaviour she engages to numb that pain. Some of these, what I'm talking about, come from my PhD, so I'm hearing families. So where did Janet and Justin think we can begin to break that cycle that keep problems going? Important to mention here also is obtaining from Janet and Justin what their goals in our work together look like. Collaborately finding ways to know we're making progress and we're moving towards those goals. The protective factors are next and they aim to draw the strengths of Justin and Janet that offer against the challenges and also activating interpersonal resources, their social support. Have there been times where Janet was feeling well and coped without substances? What supported her then? And how do we build and implement those strategies again? And in terms of the prognosis, this will depend on the context where we are working from, where we may be obliged to indicate a probable outcome for Justin, Janet and the family. By using the case conceptualisation as the anchor with which to work with Janet and Justin, effective interventions can be used to directly target and respond to the complexity of their needs rather than that a way around, rather than fitting Janet and Justin to a particular parenting program or an approach. So one of the things I wanted to quickly speak about was the cognitive behavioural approach, so core components of CBT, comprised of psyched education. So I'd want to be increasing Janet and Justin's insight into their own trauma triggers symptoms, reactions, such as the dysregulated or survival coping strategies of substance abuse and depressive symptoms like helping Janet and Justin understand their minds and themselves. Cognitive restructuring is about supporting Janet and Justin, make sense of their unhelpful thoughts about themselves and begin developing and strengthening alternative narratives. Management of emotions, so that would be supporting them to adopt a range of health-remoting behaviours such as the importance of sleep, not too much and not too little. Eating nutrient-rich foods, exercising, physical activity, really developing their sense of self and agency and their connections with other people. And of course the problem-solving skills are really, really important. This is demonstrating steps to find solutions. So just maybe as simple as helping them complete necessary forms to access services, linking them and getting them food, those basic needs. Talking to Janet about contraception, so real issues that they're facing. And again, adaptive skills, adaptive coping skills and interpersonal skills are focused on developing positive, supportive and helpful strategies and relationships that present Justin and Janet's minds and bodies with positive inputs. And we want them to encourage them, motivate them to practice these new skills and strategies again and again. So that will be key in our work together. I just wanted to finally finish and just show you the findings of my PhD research and highlight the broad theme of fighting. So parents are interviewed parents, hearers and practitioners involved with statutory protection intervention. And there was this broad theme of fighting that had positive and negative dimensions and internal and external facets. Parents were ultimately fighting for and fighting against factors within themselves and things outside of themselves after statutory protection involvement and the removal of their children and as they navigated through the process. If as a society and a system, we can meaningfully engage and support families move from that top right green box where parents are fighting against the system and powerlessness to the purple top left box where they're fighting positive children so we support them reconstruct their parental identities so that they're ultimately better able to care for their children themselves and their families. Back to you, Dan. Thank you, Mary. That was really comprehensive and interesting and getting lots of questions in our tech room about case conceptualisation in particular. So thank you very much. I'd now like to hand over to Dr, definitely Dr, Nick Tarlenko to talk from our psychiatrist, you, Nick. Thank you very much, Dan. And thank you to my panellists and of course they've discussed a number of issues and so I'll kind of step around some of the things that they've covered well as we go through my slides. So as you know, we're sort of focusing in a sense on Justin and Janet and their experiences. So often we're, you know, we're thinking child first usually, but in this particular instance, we're thinking about the impact of ACEs on the two parents, Justin and Janet. And I'll just pick out a couple of kind of features of that. Just one of Justin's historical experiences is the abuse of the hand of his stepfather. And we also kind of note that he doesn't want to be much more than a part-time dad. So, you know, one thread of asking him about his experience of being parented might be about what was that experience like for him, but of course that might be a bit too confronting at first. That's what you've got to ask him about. When he experienced these, you know, adverse experiences such as abuse by a stepfather, what did mum do to help him out? Could mum be relied upon? How did mum respond? All those sorts of aspects. And then ultimately, we could get to some questions, but it would take many steps and some good curious questioning to get to this notion of does he think that impact on his sense of wanting to be a part-time dad for tea? So is he kind of trying to protect tea from the potential dangers or demons that continue in his own life or his own head regarding his experience of abuse and fathers being abusive towards their children? So that's kind of one area we want to go in. Janet's had a lot of parents, foster parents. Maybe she's had foster siblings who she might remain close to or not. So there's a whole lot of kind of parenting figures in Janet's life and that might present some challenges about who's been most reliable, who's been consistent. And we have, if we have a look there at some of the experiences that Janet's had, we could just see perhaps this one about, just can't see it, I'll just have to bring it up a bit in size here. These kind of range of questions that we've got there and we'll explore them a bit more now in my next slide. So as we mentioned, Justin has had this experience of abuse, had a mum react. Often this really, at least starts a conversation about saying most parents want the very best of their kids and sometimes they feel that things can get in the way of their parenting. What do you think is, you know, in that domain for you? And in a sense, he's made a commitment to being a part-time father. Let's imagine what would be the impact of full-time fathering on you, Justin. What would happen, do you think? He tells us he hasn't really got a clue. Oh, so that could have a bit more exploration about what sort of ideas has he got if he hasn't got clues and how would he go about trying to get some clues? Because we know that for early parents, especially in those first two or three years of our kids' lives, same for everyone, we get so many of the clues about parenting from fellow parents and our peers who try to parent their kids and that's often where we learn so much of it. Is that a possibility for Justin? So these are kind of opening up opportunities or possibilities in the way that Courtney's talked about, the kind of eco-map potential. He talks about the impact of crying. He doesn't like it. What is his response to crying? What happens when your baby cries? Does it make you feel frustrated? You know, so you can give some clues. I wonder if this hearing tie, having a hearing-tea cry makes you feel frustrated, makes you want to run, getting a sense of what it is that these experiences might be with that. Janet's had quite a story of kind of ruptured care and ruptured continuity in that care. We want to know a bit more about how this occurred and why, because I think in her story she tells us that there's a sense of blaming herself for that. None of those foster placements seem to work. That's often an experience that kids who have been in foster care report and it's a sign that they bring in a sense of failure of the unsuccessful foster care onto themselves. Whereas often we finally peel back the history of that. They've experienced serious adverse events in foster care that can also include abuse and other experiences. And sometimes that's the cause of frequent moves in foster care. So that's one bit that needs a bit of unpacking, because that might help Janet understand a bit more about the sense of foster care may not have been of the quality that she needed to experience more continuous quality kind of parenting in her own right. There's a strong sense about Janet wanting a sort of experience of love and what is it she's hoping for? Most of what we can bring, I think, to the table about parenting in children, talking about children, of course, what is the hope? Hi, folks, welcome back. And we've just had, as I would know, we've just had a slight technical hitch. Nick, I reckon we got to about the third of your slides before you cut out. What I might do is just encourage you to maybe go back to about your third slide and we might go from there. So apologies to our audience. Sorry about that, everybody. We just had some slight technical issues and we'll now ask Nick to continue his presentation. Thanks for hanging on in there. Hello, yes. Sorry about that, everyone. So I think we were talking about Janet. And why don't I just focus on other themes in the snippets of information we have about Janet. And that's a sense of the hope of love, the hope of tea. And what was it she was hoping for? So what was the kind of experience she was anticipating or expecting? Because we know her own experience is really a ruptured parenting with, you know, discontinuity and intermittent care. And some of that might be complicated by adverse experiences that she too has experienced in foster care or alternative care. Does she have contact with her foster siblings and foster parents? And I think Mary had talked about the importance of understanding Janet's triggers to drug use because it's intermittent. As I mentioned, Janet has this kind of theme about wanting to experience love. And how's that going with Justin and his support for her in parenting tea. And other of you have talked about these aspects about her. For tea herself, of course, preventing out-of-home care is a critical issue here. And I think both Mary and Courtney are focused on the importance of a consistent, intensive approach to that being implemented in this example. We don't know much about potential antinodal and ketamine exposure, and that could well have serious effects on tea's development. And we would be really keen to know about her psychosocial emotional development and particularly her language development, the context potentially of neglect. We don't really know the extent of neglect, so we'd not want to know something about that in terms of the size and the sense of the impact as an adverse child experiences for tea herself. With tea's difficulties, but we could kind of anticipate, parenting her is actually going to be more difficult, and that sometimes can help parents like Janet understand about the sort of demands in the sense increased skill in parenting. It can be a bridge to accepting more support, parenting support. And in fact, tea's experiences into consistent care and sort of relationship quality when Janet goes in and out of use will stress a tea, and she'll actually react more. So these are kind of the contributors that could complicate the difficulties in her being parented. I think this is kind of the language that Courtney introduced. It does take a village in terms of the eco-map and all those things. Safety and monitoring, as Mary emphasized, really is priority one. But what are the strengths too, which I guess Mary raised? And how, if he committed, or what gets in the way of his commitment here, is a kind of key issue. And we could talk with him a bit about what is the sense, how much closeness to tea does he want to manage? How do you think that works? What's the impact of that on Janet, et cetera? There are a group here of intergenerational aces, which I've just picked out some of them here. And you can see that you're already, without trying too hard for tea, there's at least six half a dozen aces, and once you're at that kind of level between four and six, the adverse impacts that Mary described so well can really have their impact. We don't know much, even generically, about what's the cause of Janet's developmental disability. We don't know about the impact of potential for illness. And certainly with parents with amphetamine use, we often see quite serious weight loss during pregnancy and things like that. But we know about the importance, in this particular instance right now, about the need for a persistent, reliable, intensive intervention. Mary raised this issue. Is it time for drug rehab? Some instances that can occur with under three-year-olds, and that's a real help, often for mums in terms of entering rehab and persisting with it is having their baby with them because it really does keep them embedded in rehab often. My experience in working with mums with mild-developed disability is that the power of imitation, of watching, and this might as often as home visiting nurses, working with them and working with their infants is the critical step where learning really occurs, especially in someone like Janet with her own experience and in her head, her own memories, her own recollections, her own experiences of good quality parenting might be very limited. And that probably increases the need for kind of imitating observed good parenting. As I mentioned, there might be some health risks and Mary also raised the issues of chronic illnesses in mums and the issues of how this might affect T's growth. So that's kind of... I've talked about it a bit about T T's impact and T's experience of parenting and the parenting capacity of both Justin and Janet in number of domains. We've talked about ACEs or ACEs in this wide variety of domains potentially impacting on T and intergenerationally going back generations. Courtney's genogram was fabulous and of course in particular settings sometimes we can do genograms that stretch back in original populations. So Judy Atkinson really championed the idea of chromograms where you go back in family history to delineating trauma and ACEs often through several generations and this might be one of those families in Janet's case in particular. And wanting the best for the baby might even include temporary kinship placement. So this might be a kind of avenue about collaboratively working in the best interest of the child which might help parents get back on track. So it's really about keeping all the options open and doing it in a collaborative and supportive way. Some of these kind of questions might be around these issues. What are your hopes for your baby's child? What are your hopes for how you best want to love her? And how do you imagine your baby loving you? What's got you through as a parent? Who could you rely on when you're a kid? So those kind of ways in to asking parents about those things. So thank you very much. I'm sorry about the glitch and of course we're really happy to take questions. Thanks so much, Nick. So one of the questions that we'd like to ask you about your excellent presentation was you talked there about Justin and the fact that he was abused by his own stepfather and you talked a little bit about the fact that that might have given him an idea of the protection and his own kind of ethical kind of considerations of the sort of dad and the sort of protective figure he'd like to be. Can you just say a bit more about that? Yeah. So we've got a bit of a story about Justin's, you know, wanting to be a part-time dad, not having a clue about how to be a dad, wanting Mary, wanting Jana to do a better job as a mum. So they're all kind of, in one sense, distancing from the serious task of being a committed parent. But the kind of issue to raise is you could be curious about that as someone interviewing the family because the curiosity would be about, well, God, I'm wondering if, you know, Justin, it looks like your experience of fathering wasn't that good. Is that right? I've understood that. So you're kind of always taking this position where you're inviting Justin to comment or have I got that wrong? I didn't quite understand that. And I just wondered if sometimes, you know, when children and dads are close, do you kind of have a worry that violence might break out or do you worry about their safety? So it's possible that a way of positively connoting what Justin is doing is that, in a sense, he's going to protect tea from his potential sudden outbursts of anger or violence and those sorts of things. It's not uncommon, you know, in couples where a drug use occurs that there's quite distorted thinking and sometimes violence. And violence sometimes goes with this pattern of particularly dads as part of their controlling kind of style, wanting mums to do much better with their kids. So there's kind of a lot of issues there and I guess we haven't talked specifically about whether this is a couple which might well experience domestic violence, but there's certainly some non-specific flags that suggest that's an area worth exploring. So coming back to your specific question, Dan, it's a kind of mix of is Janet safe, firstly, is tea safe in this environment and then secondly, is Justin holding himself back, holding himself from the full commitment of kind of being a dad, wanting to be a part-time dad, because in some way he feels that's a safer way for tea to grow up and develop. Thanks so much for that, Nick. Really interesting insights, so thank you. Courtney, lots of interest in your amazing genograms, but one really interesting question, when using genograms as part of your therapeutic process, can you tell us about the steps you might take with families where adversity and trauma are present so that you can ensure safety? Yeah, for sure. I know that some practitioners can shy away from the use of genograms, especially when we're working with families from child protection around home care backgrounds, because it can be quite triggering. I suppose it's very much about talking with the client, getting them to see the benefit and how it would work out. It's really kind of no surprises, so it's not about rocking up to the home visit that day and saying, oh, we're doing a genogram. It's about really floating the idea over a number of visits, of course gaining consent that they want to do this, explain to them the reasons why we want to do it, but also make it fun. I think when you are doing it, being very mindful of where the clients come from, the presentation is during the visit, but also if you're working with a family as large as the genogram example that I provided, you're going to have to do it over a couple of visits. It's not just going to be one visit. And just take it as a pace and let the family know that they can stop and start a park here for a little bit and continue when they need to. I've rarely had a family that said, no, I don't want to do this. It's always been like, okay, I'm going to give it a go. And normally once that they've got into it, it's actually a really good process. Thanks so much, Courtney. Next question's for you, Mary. So tonight we've talked about adverse childhood experiences, but we've also touched upon intergenerational trauma and developmental trauma. So can you tell us about how those three concepts might be similar? Yes, they are. I think it's just language depending on the discipline we come from. We refer to them differently depending on the discipline, but ultimately when a child is exposed to overwhelming stress and their caregiver is unable to reduce that stress or maybe contributing or causing that stress, the child experiences developmental trauma. So most clinicians are familiar with the term PTSD or post-traumatic stress disorder, but the vast majority of traumatised children will not develop PTSD. Instead there are a risk for a host of complex emotional, cognitive and physical illnesses that last throughout their lives. So some also refer to complex PTSD and this refers to a response of repeated prolonged, repeated experience of trauma and these adverse childhood experiences. So they're all the same thing. If I could just comment now, the big thing is the accumulation of the sort of adverse child experiences. So there are large numbers of kids who face one or two adverse child experiences and bounce back in a sense. It's when you get to more than four that some of the risks for the long-term crop up and once you're at six or more, then it really escalates very quickly the chance of adverse kind of outcomes in terms of learning, development, school functioning and the other risks that you talked about born in the long run such as the mental health problems and the physical problems. That's when they really kick in. Once you've got a stack, an accumulation of more than about six or more. Yeah. So Nick, when you're working with parents and thinking about their children's mental health, do you deliberately and explicitly talk about children's mental health with parents? I will talk very specifically about the importance of relationships and being close. I'll ask them about what do they think, the factors that support resilience in their kids and language like bounce back, what helps your kids bounce back. So that's often what I focus on. Your question about mental health is a really good one because if we look at tea in this particular case example, we know that, you know, that snippet, you know, roughly about a minute, the sort of snippet we had as the preparation for this. We hear, I think it's our foster parents talking about their concerns about teas, you know, wanting to approach strangers and hugging them and getting close to them, approaching people in the street and being very close and wanting to be part of them. It's highly likely that tea really has a significant problem with how she relates relating to her attachment really as a function potentially of neglect that she may have experienced. So that's not often considered a mental health problem but of course it can be. It can be a problem of disturbed attachment or distorted attachment. So that can sometimes help particularly foster parents or parents. It's part of what I was sort of introducing is this idea that should tea, you know, be already lagging in terms of her own development, then parenting is actually going to be a lot more difficult and that's partly what you're getting, I think, in that feedback from the foster parents. Parenting tea is a lot more difficult. She's much more subject to emotional kind of regulation up and down. She tells them she hates them. So you've got really strong emotions that she can't manage plus she's got this really fundamental problem about how she relates to people. In fact, in a sense she's so attention seeking that she'll hug people who are strangers and of course you can see how in the long run that's potentially a risk unless it can be a reverted because it puts her at risk of approaching people, strangers, incredibly warmly, almost intimately and potentially putting her at risk. So there are some mental health problems already emerging in this but it's always a kind of judgment call about how much you call the mental health problems because people often hear that as mental illness from which my kid will never recover but there are other common mental health problems, you know, like ADHD and all the others that arise that are in a sense much more readily accepted and discussed but regardless of whether you talk about mental illness or not, I think the issue is that you can identify the problems and talk about them and ways to address them. Thank you. I don't know if my panel members want to comment on that because Mary kind of touched upon that but didn't really explore it but certainly an example with T, she's a kid who looks like from a relational point of view and her capacity for relationships, she's already in trouble. Yeah, Mary, would you like to comment on that? I mean, supporting T with... I'm not familiar, sorry, with the other case study but certainly supporting T with her emotional regulation and keeping it in a safe environment and ensuring it's really, really critical and not seeing it as the behaviors of T but their symptoms of what she has experienced in her short life. Thank you, Mary. So we've also got a question from Anusha in the chat room which is a great question, really talking about how does a panelist manage parents' expression of shame when they are discussing their children's wellbeing and the fact that this might make them more reluctant to engage in conversations. Courtney, I wonder if you'd like to respond to that. I think it's a great question and I think that for me it's really about... Oh, I think there's a lot of ways that you can respond and no real words are kind of coming to my head but I think that when we're working with families with complex issues and trauma background, shame is a very normal emotion to have so kind of really supporting them through that and normalising it in a way that's not going to obviously impact on child safety is a really good approach but I think as professionals we really need to be able to have the skills to sit there in that uncomfortable space because if we're uncomfortable in that space the family is going to be uncomfortable so to kind of work through that together I'm not sure if I've 100% answered the question there, Dan. Dan, I think you're on mute. Thank you. Sorry about that. So I might now throw to you, Mary. Mary, what do you find important in terms of working with parents who might be feeling a sense of shame or who also might be feeling a reluctance or a resistance to engaging with you in therapy? Well, we know that parent worker engagement is crucial in supporting the change necessary for adults who have experienced adverse childhood experiences or developmental trauma. If there is that disengagement or resistance from parents or adults I would look at... I mean, this says more about our approaches and our style of interactions with those whom we are serving. So resistance happens when we expect or push for change when the parent may not be ready for that change and we would expect that this is normal because change is hard. Change is really difficult. When there's that resistance I would be open to exploring that those emotions, those really strong emotions with parents emphasise with them, develop discrepancy such as some of the behaviours don't mesh with the important goals. So you say that your children are really, really important but you're not able to put their needs first. How do we work with that? So change won't occur without a discrepancy. So highlighting for the parent where that gap may be and where they're at and where they want to be is really, really important. So that change talk, keeping them at that change talk. But first of all, again, remember these... Parents who have experienced adverse childhood experiences are working at that threat stress response. So it's impulsive, it's reactive. We're thinking... Action first and thinking comes later. We need to create a relationship with them, build that trust, understand that shame that this isn't what they wanted for their children and this was better than what they had when they were growing up themselves and that we can create that discrepancy support through that change. I think is really important. That's a really, really great answer to that question and to be thinking about the importance of engagement. So we're now moving towards the final stages of our webinar tonight, which has been really interesting and engaging and so I thank all of our panellists for their excellent presentations and answers to our questions. What I'm going to do now is hand over to each of our panellists just to sum up for a couple of minutes and to leave us with maybe a final observation. So Courtney, I might start with you if that's okay. Yeah, that's cool. I think to sum up what we've discussed here is really something that Nick was talking about. Is that ACEs are actually relatively common and yes, when we get into the pointy end of six or more we can start to see some real developmental concerns and later in life health concerns. But to always be mindful that when we're working with families and especially parents is that it's likely that they are going to have a number of ACEs and there's always be trauma informed and to always keep the children's well-being and safety in the forefront. We all work with highly complex families and sometimes I think complexity is becoming more and more. So really use some of the tools that we've discussed here to break down those cases and try and really don't ever underestimate the importance of engaging with a family. We know all about the therapeutic alliance and if you're not able to have those conversations with families really use your supervision space to really kind of see where you can kind of enhance your engagement skills. I think that's probably the most I have to say so I might hand it back over there. Thank you Courtney. Mary, I might hand over to you now. So I just wanted to finish off with talking about supporting parents through that therapeutic alliance about reconstructing their sense of self. So it's about learning, supporting them to learn in ways of seeing themselves, managing their stress differently, learning to regulate and manage their emotions. So this may be a range of activities to be able to do this. Keeping them relaxed and calm rather than angry and in that stress response. Teaching them to learn that asking for help doesn't mean that they're failing, that they're a community. We want to be able to activate their interpersonal resources, personal resources and community resources. So supporting them be able to reflect and also develop those healthy relationships with other people. And we can't create that change until we have an alliance and a relationship with them. Back to you Dan. Great. Thanks Mary. And Nick, I'll now ask you for a final comment and observations. Thanks Dan. Look, I think the panellists really highlighted the essence of the requirement for safety and security in a relationship. But there's two things you're often holding in balance. Partly spitting off the question about shame is that in the context of shame it usually means you've got to go slowly and carefully. You have to be collaboratively alongside parents as a way of establishing trust. And it's where this sort of curious approach to some extent that we've been talking about a lot in these series of seminars is really important because it's the not knowing bit and getting them to fill in the information and the space because that's where the shame might pop out. The shame drives avoidance. So a lot of these families that we see, avoid services like the plague, let alone if they've been badly treated by them, it's not sort of a case for people like in general situations. And that avoidance is what can only be addressed very slowly. But the tipping point, the balance point is what about tea? Tea can't actually wait a very long time for the kind of slow work to happen. But it has to happen because there's only way to manage the pair. And I guess the thing I want to just make the people who are very clear about is that teasing is a serious trouble and teas in trouble are quite a very serious relationship level. And the best bet is care by her parents and the support for her parents. But what's missing in the story is the extent of the intense engagement with parents to make them safe and secure enough to be tea's parents. So that's the kind of bit that's critical, I think. The only thing that I think Mary touched upon a bit earlier was the importance of peers. So then in one of the services I worked with kind of works across this kind of mental health, child protection, drug and alcohol interface, is that one of the things we work to do to engage parents is get them, the ones entering the sort of program, to meet with other parents in the family. Because this is another way of modulating the impact of shame. You've got peers who can tell you stories about how they got through it. Peers who can tell you as parents how they came from being behind the eight ball to getting on top of their game as parents. That's at least as influential, if not more influential, I think, than specific therapeutic work. Not to say that I think in the context we're looking at here, tea may well benefit from specific therapeutic work, but probably in the context of a family-based approach, or a dyad with mum, or a dyad with dad, or with a couple together. So therapy's not about sort of tea alone, it's about tea with her parents together. Once the kind of bigger issues about the structure and the framework for safety and security are well established, and trust is at the core of the relationship. Thank you once again to our panellists, Cornish Sherman, Dr. Mary Salveron, and Dr. Nick Kalilenko really appreciated your insights tonight. Okay, so that's moving towards the end of our webinar tonight. There are resources and further reading for you, so other supporting resources can be found in the Supporting Resources tab at the bottom of your screen. And of course, for more information about emerging minds, please visit our website at www.emergingminds.com.au. So thank you for participating tonight, again, we really love it if you could click the Feedback Survey at the bottom of your screen and be able to provide us with some feedback about your experience time. Certificates of attendance for this webinar will be issued as part of the MHPN's conference, and they'll be issued by the end of this month. Each participant will be sent a link to the recording of this webinar and associated online resources within about four weeks. So this webinar, as we've mentioned, is the final activity in the trauma, the impact of adverse childhood experiences content stream in the MHPN online webinar conference, Working Better Together. So a few words about the partnership between MHPN and Emerging Minds. This webinar was a co-production between those two partners. The National Workforce Centre for Child Mental Health is facilitated by Emerging Minds and delivered in partnership with the Australian Institute of Family Studies, the Australian National University for Parenting Research and the Royal Australian College of General Practitioners. MHPN supports the engagement and the maintenance of a practitioner network so that clinicians from different disciplines meet regularly with other mental health practitioners, share tips and resources, and build referral pathways and engage in professional development activities. To learn more about joining your local practitioner network, please visit MHPN.org.au. And before I close, I'd just like to thank you all that the more than 500 of you that joined us tonight and just acknowledge the consumers and carers have 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.