What is the toxic stress reaction?
The Center on the Developing Child at Harvard University, defines the toxic stress response as—“ occurring when a child experiences strong, frequent, and/or prolonged adversity—such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship—without adequate adult support. This kind of prolonged activation of the stress response systems can disrupt the development of brain architecture and other organ systems, and increase the risk for stress-related disease and cognitive impairment, well into the adult years.” Harvard Developing Child
Neuroscience teaches us that prenatal to the first year of life, important brain developments are occurring. During this time, healthy adult interactions, stability, nurturance and predictability help to create healthy emotional and cognitive development. If these factors are absent for extended periods of time, brain development will be negatively impacted and toxic stress is likely to occur. Further, this stress will impact learning, behavior, social, and cognitive development. Nerve cells responsible for communication become compromised and the ability to respond to things appropriately becomes limited. This puts children at risk for depression, cardio vascular disease, frustration tolerance, emotional regulation. It is important to note that, early intervention is helpful in counteracting these negative effects. Parents, day care providers, therapists, doctors and educators can counterbalance toxic stress.
Toxic stress causes failure in neurons to develop properly. Why are neurons important? Neurons are the building blocks of the nervous system. They are responsible for chemical and electric messages in the brain. It was once believed that we are born with a certain amount of neurons at birth but recent scientific discoveries have determined this not to be true. Neurons
The brain is shaped by experiences and is expecting to have these experiences that will help it to develop in healthy ways. When these experiences are disrupted by abuse, neglect, instability, stress, and learning, there is a devastating effect on the brain. The brain begins to lose its flexibility, electrical circuitry which all wears down the brain. Early development impacts almost everything else that comes in later life—learning, relationships, emotional regulation and so forth. This has lifelong consequences for the child. Science shows that toxic stress in children reduces neural connections in the brain.
The Stress Reaction
The stress reaction is a normal response to perceived or real threat. The body kicks into high gear, adrenaline starts to pump, heart rate increases and it becomes fight or flight time. Once the threat disappears or lessens, the body returns to its normal homeostasis. In young children, the stress response can be lessened by the attentiveness of a parent or guardian thus helping the body to quickly return to normal. When the child is unattended to during stressful times (abuse or prolonged neglect) and the stress response is allowed to stay at a heightened level, toxic stress begins to develop. Over time, this becomes permanent.
Overview of toxic stress:
• Body and brain go on high alert
• When the stress is relieved-the response declines and the body goes back to normal
• Abuse and neglect allow the stress response to stay activated therefore causing significant damage to neural connections.
• No response from a caring adult prolongs the stress response
• Repeated stress response weakens, overloads developing systems
• It thwarts normal development Areas of the brain for reasoning and coping becomes weakened.
• Environments need to be nurturing and stable to avoid toxic stress.
Counteracting Toxic Stress:
Responsive and caring adults play an important role in counteracting toxic stress. Adults who are charged with the care of children can assist in decreasing toxic stress. Parents can be taught about the importance of brain development and learn how to interact with their young children to decrease toxic stress. Parenting and nurturing does not always come naturally, but studies have shown that parents can be taught to practice and use nurturing skills.
Teachers can attend to child in compassionate and nurturing ways. Early childhood educational centers provide safe, stable environments and offer supportive services that help with the effects of toxic stress.
Social workers and other mental health professionals have the training and skills to work with children who suffer from toxic stress. Social workers have training to work with families in adversity. Additionally, with specialized training in trauma focused therapy, social workers have skills to help children with toxic stress. The unique perspective of understanding ‘the person in the environment’, is crucial in assessing children at greatest risk.
Teaching children mindfulness training is helpful to counteracting toxic stress. Mindfulness is focused attention to internal and external experiences as they are occurring. Mindfulness has been used in the treatment of stress, depression, anxiety, ADHD, chronic pain and many other chronic conditions. This recent study shows how after a short lesson in mindfulness training improved the concentration of children. Mindfulness Study
All too frequently, there are reports of violence in schools. This week alone, a teacher was killed and two students injured, in Las Vegas. In Massachusetts, a teacher was killed, allegedly by a 14 year old student. In Washington State, an 11 year old boy brought a gun and knives to school. The level of violent acts is overwhelming and scary.
Mental health professionals are trained to assess dangerousness and with the increase in violent acts, we’re being called to do so this on a more regular basis. It’s tricky at best because behavior can be as unpredictable as the weather. I’ve been asked to complete assessments and render an opinion on children who were thought to at risk for violence. I used the standard means of, gathering past history, assessing current level of stress and agitation, determining intention, access to weapons and family history. There have been times when it became absolutely clear that there was high risk for dangerous behaviors, other times, not so much. I feel a tremendous sense of responsibility when conducting such assessments and almost always include a caveat, of “this is my best judgment based on information gathered today, but other influences could impact this determination at any time.”
I’d rather not be asked to assess for dangerousness. I’d much prefer to work with children and prevent conditions that contribute to things escalating to thoughts and acts of violence. Unfortunately, by the time that a potentially dangerous student gets referred to me, he or she is, entrenched in negative thoughts, overwhelmed by feelings of rejection, feels hopeless and victimized. Along with family dynamics, these experiences increase a child’s propensity toward violence or self-harm.
• A positive, affirming relationship with a safe adult
• Involve parents in the assessment and treatment—it is important to assess if there are family dynamics contributing to child’s problems
• Recommend that parents remove guns and other weapons from the home
• Get child a psychiatric evaluation for depression or other condition. Medication might be indicated
• Refer for higher level of care if child is having active thoughts of violence to self or others
• Teach mindfulness or another form of relaxation—this helps with emotional and physical regulation.
• Get child connected with activities—this will help to foster a sense of self confidence and increase a child’s self-esteem.
• Teach social skills that include understanding and practicing empathy for others.
• Challenge negative and distorted thoughts. Help replace with more realistic and positive ones.
Always trust your gut. If you feel concerned about a child, act on it. You are responsible for protecting that child and perhaps the lives of others.
Like many helping professionals, I had a bad habit of overextending myself. I took on too much and almost never said, no. I found myself wrought with anxiety and deep in burn out. Overcome with despair and desperation, it became increasingly unhealthy for me to think that I could continue at that frenetic pace. I needed a change and it needed to happen immediately.
I stopped taking new referrals. Sure, others weren’t happy to hear this, but I made myself the priority. I stopped working three nights a week and only see clients until 5pm. I placed a higher value on my time. If clients required paperwork or other services that weren’t billable, I instituted a fee for this work. Next, I delegated some responsibilities to other therapists in my practice. I created positions and compensated more senior therapists accordingly. This was huge and had a positive impact on decreasing my stress level.
What I did next was difficult, but necessary—I terminated five therapists who were high needs, chronic complainers and energy drainers. They were spreading a poison in my practice and before things got out of control, they were terminated. There was a short term disruption to services, but my other staff rallied and we pushed on.
Previously, I had little time to do things that I find refreshing. I reignited my love affair with daily exercise. Oh, how I missed my exercise. Now that I get home at a respectable hour, I can crank out an hour–it’s so good for my heart and soul. I added mindfulness practice to my life. That alone, has been life changing. It has stopped me from projecting myself too far into the future and increased my awareness of the now! I’ve learned to slow down, become more thoughtful and less reactive. I’ve learned to let go of fears, manage others’ expectations of me and have more realistic expectations for myself. I’ve incorporated more social activities, too. I love entertaining, getting lost in cultural events, and traveling.
Things I’ve learned about taking better care of myself:
Last week was Mental Health Awareness week. I participated in a tweet a thon with other mental health organizations to spread the word.
I wonder what it would be like if there were no stigma against getting help for mental and emotional difficulties. Would there be less suffering? Would the suicide rate decrease? Would there be an increase in overall life satisfaction? The joy in working with children is that they are not as cognizant of the stigma related to mental health. It’s only as we internalize the messages from parents, society and others that we endure suffering.
Did you participate in any mental health awareness activities? Do you identify yourself as an advocate?
We’re back in school and without missing a beat, I am super busy. There were two mental health crises greeting me when I walked into the school. Additionally, I’ve begun reconnecting with students who have previously received services. Some of them were seen over the summer, but others decided to take a break and resume counseling during the school term. I’m happy to be back and feel like I’m at my best working in schools.
I love middle school students. They are emotional and drama prone but so amenable to the counseling process. Some are seeking a warm, safe adult to connect with; others have significant mental health disorders that reveal themselves at this stage of development.
I’m noticing that anxiety is increasing among middle school boys. Typically, we think of girls as being prone to anxiety but in the past few years, I’ve had many referrals of boys who have overwhelming anxiety. They struggle to come to school and once they do, the symptoms of anxiety often overwhelm them. I struggle to understand why it appears that there is an increasing trend of anxiety in boys? Is it because we acculturate boys to be strong and suppress their feelings but that burden is too much? Are we just realizing that boys are as impacted by anxiety as are girls? I don’t know. However, what I’m seeing in these boys is often debilitating and significantly impairs their academics, social and peer relationships and puts tremendous strain on their families.
My approach is multidimensional. I create a team with, the parents, school counselor, school nurse and student. We develop a plan that includes the input of the student. Often times the plan includes, the ability to use a pass to visit with the school counselor or nurse if anxious. During these visits, the student will be encouraged to practice deep breathing techniques taught in therapy. If there is school avoidance, and often there is, the parents must agree to get the child to school. We find that parents often feel guilty and collude by allowing the child to stay home. This only reinforces the aniety. We also provide individual and group utilizing cognitive-behavioral techinques. Studies have shown that CBT is the optimal treatment for anxiety in chldren. Treatment typically takes 6-8 weeks before we begin to see a decrease in the symptoms of anxiety. Sometimes, it becomes necessary to refer for medication evaulation.
As the new school years begins, I’ve already started identifying students who would be appropriate for an anxiety group. Middle school children are very peer oriented so it is easy to get them to agree to group work. Additonally, they benefit from knowing they’re not alone.
Children with anxiety should always be taken seriously. It is a very disruptive disorder and leads afflicted individuals feeling desperate. With treatment and support, they can learn how to cope.
Watch this video for more information: Children and Anxiety
Social workers have long been proponents of community based work. However, as private practice opportunities increased, the desire to make more money, and complications imposed by insurance companies, social workers have found comfort and stability by adapting to the traditional medical model of practice.
However, I challenge social workers to retreat back to our original roots and return to community based practice. By integrating with local schools and community centers, I’ve built a successful practice. I am among a few child therapists in my state. The need for services for children is huge and not likely to decrease in the foreseeable future. The question I asked myself is, if children are going to receive quality mental health services, how and who will provide them? If I consider myself an expert, how will I use my knowledge to assist those in most need? If I’m sitting in an office located in the suburbs, how will families who live in cities and rural areas reach me? I solved many of my own questions and concerns by developing a model of practice that has worked well in schools and other community settings. I’ve grown from 2 therapists to 12 over the past three years. Collectively, we provide services to over five hundred children during the school term.
Here are five reasons why you should consider this model of practice:
1. Social workers have roots in community based practice. How are you achieving this goal?
2. No show rates are very high in most office based practices. Being in schools decreases the no show rate tremendously.
3. As practitioners, we have the responsibility to educate others about mental health issues. Schools provide an audience who want more resources and educational opportunities
4. Advocacy—this is another traditional role and value of social workers that we sometimes slip away from. Being in a school setting allows us to advocate for children in very meaningful ways. For example, how many schools recognize mental health disorders as ‘real’ medical disorders and provide accommodations? Having a practice in the school allows you to advocate for your clients on the spot.
5. De stigmatize mental health and therapy—Ha, imagine social workers playing a role in decreasing the stigma of mental health and therapy! It’s what we do however, if we’re ‘invisible’, how does that happen? I’ve found that children are the least judgmental when it comes to mental health and counseling. Therapists in schools have ability to reinforce the normalcy of asking for and receiving help.
Bonus: You can increase your practice revenue. After all, we need to make money and receive compensation for the good, hard work we do. Providing services in schools eliminates your no show or cancellation rate. Parents and children are more compliant because you are reducing many obstacles that make it difficult to get to your office.