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The NeuroRelational Framework (NRF): Translating Brain Science into Clinical Practice

Connie Lillas, PhD, MFT, RNNRF Global Communities www.nrfgc.com 1

The Neurorelational Framework: Translating Brain Science into Clinical Practice

Connie Lillas, PhD, MFT, RN

www.nrf‐gc.org

Outline

• Our cultural context at‐large; mismatches in neurodevelopment from various venues

• Promotion: Universal Key Concepts About Brain Development

– Brain Architecture

– Serve & Return

– Toxic Stress

• Prevention: Strengthening Connections

– Assess and Support Adaptive vs Toxic Stress Patterns

– Assess and Support the Serve and Return Process of Engagement

• Intervention: Individual Differences & Community Building

– Using Individual Differences for KnowingWhen to Work Bottom up & Top Down

– Building Cross‐Sectored Communities

Compliance vs Non‐Compliance

In our culture, we are taught…

• Challenging behaviors = compliance and non‐compliance

• Solved using rewards and punishments

• Often blame parents



National Survey, 2016 ‐ZERO TO THREE

National Survey, 2016 ‐ZERO TO THREE

False Assumptions! Top Down vs. Bottom Up

Top‐Down Capacities

Bottom‐Up Capacities

Face‐Heart Connections!

SAFETY VS. THREAT



Mismatch of Parental Expectations

• Our children’s chronological age does not always match his or her developmental age

• Disappointment is unmet expectations, and the more significant the expectations, the greater the disappointment

• The greater the disappointment, the greater the stress response, the greater the chance of toxic stress!

Mismatch within Large Systems of Care ‐ Child Welfare System

• Assume that if parents take a parenting class and go to an Anger Management class that they are ready to reunite

• All top‐down information without any bottom‐up lived experiences for how to manage stress levels, how to repair relationship, and how to get resilience back on line (or begun)

• Knowledge is a Rumor Until it Lives in Your Body

Mismatch of Professional Expectations

• Our medical systems of care often assume that adults make deliberate, top‐down “choices” to be unhealthy or healthy

• Safety vs. threat often is not considered as part ofautomatic behaviors that promote emotional safety even though they may be medically “unhealthy”

• The greater the adverse experiences the greater thechange that toxic stress is driving the adult onset of “diseases”!

>400lbs. (185Kg)

againinashorterperiodoftimethantheweight

waslost.

Weeks

Felitti. 2012

‐Centers for Disease Control and Prevention (CDC) and Kaiser Permanente, 1998‐17,000 middle‐class Americans answered questionnaires‐Past childhood experiencesCurrent health and behaviors

Mismatch of Evidence‐based Treatments

• Our children’s chronological age does not always match his or her developmental age

• When our clinics are parsing out who is getting trained in what EBT and who gets what client, there may be a mismatch between bottom‐up & top‐down needs

• The greater the mismatch, the more the treatment will not work or the longer it will take or the family will drop out



Experiences Build Brain Architecture‐Video

https://www.youtube.com/watch?v=VNNsN9IJkws&list=PLI-R9dGMpDvu9YGNjUe5TUSBSREclLwcs&index=5

•Motorplanning•Plan&sequence•Theoryofmind•Language

EarlyCare&Education

•Emotions•Memories•Meaning‐making

• Nutrition•Sleep/awakecycle•Stress&StressRecovery

•Sensations•Processing&Modulation•Speech

DevelopmentalDisabilities

MentalHealth

BasicNeeds/Medical

STEP3:BrainArchitecture‐Micro&MacroLevels

EXECUTIVE

RELEVANCE

REGULAT

ION

SENSORY

Lillas&Turnbull,2009

ChildWelfare

PreventiontoDetention

Serve and Return‐Video

https://www.youtube.com/watch?v=m_5u8-QSh6A&index=6&list=PLI-R9dGMpDvu9YGNjUe5TUSBSREclLwcs

Toxic Stress Derails Healthy Development‐Video

https://www.youtube.com/watch?v=rVwFkcOZHJw&list=PLI-R9dGMpDvv4QT2_eXmXzqyvJw9W8fgx&index=5

Cascade Effect

• Toxic stress disrupts circuits that exist….”estimate that over 80% of foster children they examined suffered from

developmental, behavioral, or emotional problems (between two and eight times the national averages).”

Stock & Fisher, 2006, Child Welfare League

• Neglect disrupts the firing/wiring of brain architecture & circuits

• In 2010 alone, neglect accounts for 78% of all child maltreatment cases nationwide, far more than physical abuse (17%), sexual abuse (9%), and psychological abuse (8%) combined. In Brief, The Science of Neglect, pg 2.

• Finally, the vast majority of children who die as a result of child maltreatment are victims of neglect (72%) alone, or in combination with other forms of maltreatment (DHHS, www.childwelfare.gov, 2014).

The NRF is a framework that translates brain science into practice :

Three Core Concepts:

• Stress Resilience versus Toxic Stress

• “Serve & return” levels of high quality engagement

• Development of brain networks

Assess & Intervene:

• Step 1: Adaptive vs. toxic stress

(roots to a tree)

• Step 2: Age appropriate vs. poor serve and return

(trunk of a tree)

• Step 3: Age appropriate developmental capacities vs. delays or disorders in brain architecture

(branches of a tree)

C. Lillas, adapted from Lillas & Turnbull, 2009



1. Adaptive vs. Toxic Stress

2. Serve and Return

3. Strengths & Vulnerabilities in Brain Architecture

Step 1: Adaptive vs Toxic Stress

http://developingchild.harvard.edu/index.php/resources/multimedia/videos/three_core_concepts

Step #1: How do we identify stress & stress recovery ?

A. Recognize three primary stress responses and who we are at our Worst!

B. Recognize four toxic stress patterns

C. Recognize what stress recovery looks like and who we are at our Best!

UCB, C. Lillas, © 2014

What is stress? What does it look like?

• While our culture often defines that our children’s behavior as compliant or noncompliant, our first response needs to understand that this is likely a stress response

• When we are challenged or under threat, there are three Automatic Nervous System stress responses

– Red zone with gas

– Blue zone with brake

– Combo zone with gas and brake

Face‐Heart Connections!



Lillas & Turnbull, © 2009

Connie Lillas, PhD, MFT, RN © 2010

Reading Non‐Verbal Cues:Red ZoneA Baby’s Flooded State:

A Baby’s Shut‐Down State

Reading Non‐Verbal Cues:Blue Zone

A Baby’s Vigilant State:

Reading Non‐Verbal Cues:Combo Zone

Arousal Zones Across the Lifecycle

– Green • Calm, alert

– Red• Hyperarousal• Flooded

– Blue• Hypoarousal• Dissociate

– Combo (red/blue)• Hypervigilant• May look calm outside, but anxious inside

& Deep Sleep Cycling

Chronic Stress

Alarm Relaxation

Normal and Long‐term Stress:

The Importance of The First 3 Years Experiences Lay Down Reactions to Stress



Step #1: How do we identify toxic stress patterns?

Recognize stress responses that are

too frequent, too quick / intense, too long 4 Toxic Stress Patterns

1. Stress responses that occur too frequently and too quickly– Any color, three or more times a day; intensity level 7 to 10 (0‐10)

2. Prolonged stress responses that take too long to recover – Any color, takes 20 minutes or more to recover

3. Cannot adapt to “normal” challenges and transitions– Any color, caregiver spends 30% or more of day with stress zones due to

transitions or stress zones lasting more than four weeks after a new routine is in place

4. Cannot recover from stress response back to baseline health – Less than 20% green zone, often with disrupted sleep cycle as well

• McEwen (2002); Lillas (2016)Connie Lill, PhD, MFT, RN © 2010

Challenge Your Community’s Assumptions!

Assume “non‐compliant” behaviors emerge from:

Stress responses ‐Threat or Challenge is too great

Differences between chronological age and developmental age

Need for Safety, which comes through relationships

There is a need for co‐regulation & scaffolding

Calm the body and the mind through your relationship

Connect before you correct!

What is Stress resilience on a body level?

• On an Individual Level There Are Two Zones:

– These require conditions of safety

First Deep Sleep Cycle is restorative Second Green Zone when awake


What’s the quality of the baby & caregiver’s sleep? • Can your baby get to sleep?

• Can your baby stay asleep?

• Does your baby get enough total sleep?

• Does your baby wake up and feel refreshed?

• Does your baby wake up and feel tired and cranky?

• What about the

caregiver?

UCB, C. Lillas, © 2014

Getting Enough Sleep

https://www.chs-ca.org/_docs/FEP_Sleep_Eng_print.pdf

Newborn with Dad

• https://www.youtube.com/watch?v=TU0f8a3Cizo



Step Two: Levels of Engagement

“serve & return”

http://developingchild.harvard.edu/index.php/resources/multimedia/videos/three_core_concepts

“What fires together, wires together”

Strengthening Families and theSix Protective Factors

These can all be linked to relationships!

(1) Parental Resilience (stress recovery)

(2) Social Connections

(3) Concrete Supports in Times of Need

(4) Social Emotional Competence of Children

(5) Healthy parent and child relationships * added

(6) Knowledge of Parenting and Child Developmentwww.strengtheningfamilies.org

Step Two: Levels of Engagement

How “thick” or “thin” is the trunk?

Building on Positive

Procedural Memories

Building on Negative

Procedural Memories

Step Two: Levels One and Two

1. Getting calm (green) together

From birth to three months an infant’s capacity for “Green Zone” grows. When an infant is in the green there is opportunity to take interest in the sights and sounds and movement of the world.

2. When calm able to experience comforting contact through…

making visual contact (eye contact/look at faces), or auditory contact (vocalize or sing together), or movement contact (rock together), or tactile contact (cuddle together), or olfactory contact (smelling together) that you both find comforting & connecting

SE Milestone Language Adapted by Connie Lillas



Step Two: Level Three

• When experiencing comforting contact able to share joy.

– During the first four months, infants and parent become more intimate as they interact with warmth, trust. Hugs, songs, looks, dancing and reading together provide opportunities to enjoy each other and fall in love.

– Over time the child will remain engaged across a full range of emotions.


Step Two: Level Four

• When sharing joy, able to create a continuous back‐and‐forth flow of communication

– By nine months, purposeful, continuous flow of interactions with gestures and expressions develops. As the infant gains motor control, the ability to point, reach, grab and drop objects, creep, sit, roll, crawl all support this back‐and‐forth flow.

– “Circles of communication” are when the flow is continuous.


Step Two: Level Five

• When in a flow, able to expand non‐verbalcommunication through an increasingly nuanced ability to read emotional cues, intentions, gestures, and to solve problems.

– By 18 months, the infant has learned the patterns of the back‐and‐forth flow and begins to use this awareness to think about how to solve problems or get what he wants i.e. pulling Mommy’s hand to the refrigerator to get a snack.

– Later, as verbal language expands this task is carried out verbally.


Stress Response System

Rupture and Repair Cycles

Step Two: Level Six & Seven

• Six: When sharing emotions, able to create stories via symbolic play & pretend play, with developing language skills

– Beginning at 24 months, toddlers are able to represent intentions, ideas and feelings in imaginative play or with language using words and toys.

• Seven: When using emotional stories, able to make‐sense and solve problems together

– Emerging during 36‐48 months, children can bridge and combine ideas to use emotions in play to solve problems.


As you get more green, go for comfort & joy!

• Some parents never had never had experiences of being soothed with joy themselves or with their child (history of neglect) so there will no gleam in the eye seen with reunions

• Some parents, even with a history of abuse, may have had experiences of joy with their children and the “procedure” of joy can return

• ASK: Do the parents recall any ways they laughed with their baby/child before? How did they use to play?



Fostering Family PartnershipsPhilosophy

• #1 goal is to provide “best practice in concurrent planning” by stabilizing the infant’s relationships (step #1, 2, 3)

• #2 be part of a system that provides additional birth parent support through coaching and modeling for reunification

• #3 support opportunities for coaching and mentoring to all involved in infant’s life with your team members

• #4 support “shared parenting” approach between all parents

• #5 provide open‐ended relationships for all parties

Old System

BabyKinshipParent

BirthParent

Shared Parenting –Fostering Family Partnerships

Baby

TherapeuticParent

BirthParent

Adverse Childhood ExperiencesLinear increase in negative health/mental health outcomes as number of adverse childhood experiences increase

Mom’s Events include ‐ 3: Abuse

Physical Abuse

Emotional Abuse

Sexual Abuse

Neglect

Physical Neglect

Emotional Neglect

Household Dysfunction

Family Violence

Parental Mental Illness

Separation or loss of a parent

Parental Incarceration

Parental Substance Abuse

Child’s Events include ‐ 5:Abuse

Physical Abuse

Emotional Abuse

Sexual Abuse

Neglect

Physical Neglect

Emotional Neglect

Household Dysfunction

Family Violence

Parental Mental Illness

Separation or loss of a parent

Parental Incarceration

Parental Substance Abuse

Cumulative Risk Factors

0

1

2

3

4

5

6

7

8

9

Regulation Sensory Relevance Executive

9

3

7

6

4

7

8

4

# O

F R

ISK

FA

CT

OR

S

BRAIN SYSTEM

Vulnerability of 4 Brain Systems

Mom Child

Links to History Worksheet



“Just Right”

Spacey

Glassey eyed

Tuned out / Flat

In own world

Flitting

“Tantrum”

AggressiveAnxious

Green= 5%Red=45%Combo=2%Blue=50%

Step One: Child’s Colors

Adapted by Jessica Richards fromInfant/Child Mental Health, Early Intervention and

Relationship‐Based Therapies: A Neurorelational Framework for Interdisciplinary Practice, by Lillas & Turnbull, 2009

Adapted SE Milestones by C Lillas, 2014 BOTTOM UP From Greenspan, 1985; Greenspan &Wieder, 1998; Axis V from the Diagnostic Classification (R): 0-3 (2005)

Step # 2

Level 7. When sharing feelings, able

to make-sense and solve problems

together (by 36 to 48 months)

Level 6. When reading cues, able to share

feelings with others through pretend play

and/or by talking (by 24 to 36 months)

Level 5. When in a flow, able to expand and

read non-verbal emotional & gestural cues

(by 13 to 18 months)

Level 4. When sharing joy, able to create a

continuous back and forth flow of communication

(“circles”) (by 9 months)

Level 3. When making comforting contact, able to share

joy & fall in love (by 5 months)

Level 2. When calm, able to make visual contact (eye contact/look at faces), or auditory contact (vocalize or sing together), or movement contact (rock together), or tactile contact (cuddle together), or olfactory contact (smelling together) that you both find comforting & connecting (by 3 months)

Level 1. Getting Calm (Green Zone) Together

(by 3 months)

TOP DOWN

Levels of Engagement

Step Two Transitions & Challenges

• Following 5 months of Shared Parenting non‐relative foster placement, child was brought back to grandmother’s house

• As a result DCFS required teen mom to have separate housing

• Without stable housing, teen mom destabilized

• Child was in a licensed, yet low quality daycare center with poor engagement and he was sedentary in a high chair


Step # 2

















(by 3 months)

TOP DOWN


Step Two




Step # 2

















(by 3 months)

TOP DOWN


Step Two Occupational TherapyTrans‐disciplinary Work

• Meet the child as his/her physical level and where s/he is comfortable

• Rewards emanate through the relationship of role transferring work

Planting Seeds of Connection…May Take Time to Grow

Triggers and ToolkitsOrganize Bottom‐up & Top‐down

STRESS TRIGGERS RECOVERY TOOLKITS

Body (Regulation)

Regulation (Body)

Sensations (Sensory)

Sensations (Sensory)

STRESS TRIGGERS RECOVERY TOOLKITS Feelings (Relevance)

Feelings (Relevance)

Thoughts/Planning (Executive)

Thoughts/Planning (Executive)

Triggers for Mom & Child –Symptoms

• Speech delay (apraxia)

• Lack of joyful exchanges

• Clumsiness, falling and tripping frequently

• Little eye contact or engagement

• Flitting around from object to object

• Marginal green zone

• “Stuffing cheeks” with food

• Profound loss due to adoption

• Mom challenged with multiple demands from Probation and Dependency Courts

Triggers for Mom & Child –Symptoms

• Mom history of Juvenile Hall (trauma)

• Under‐responsive to sensations and facial cues

• Weak visual‐motor coordination

• Lacks core strength

• Mom’s substance use

• Hitting & biting when upset

• Teem Mom’s Immigration, with separation from her own Mother from 2 to 8 years old

• Glassy, glazed eyes



Organize the Case Neurodevelopmentally!

Regulation Factors

• Flitting around from object to object

• Marginal green zone

• Mom’s substance use

• Hitting and biting when upset

• Glassy, glazed eyes

Sensory Factors

• Speech Delay

• “Stuffing cheeks” with food

• Under‐responsive to sensations and facial cues

• Weak visual‐motorcoordination


Relevance Factors

• Lack of joyful exchanges

• Little eye contact orengagement

• Mom history of Juvenile Hall (trauma)

• Immigration (trauma)

• Profound loss due toadoption

Executive Factors

• Clumsiness, falling & tripping frequently

• Weak visual‐motor coordination

• Lacks core strength

• Mom challenged withmultiple demands from Probation and Dependency Courts

Toolkits for Mom & Child for Stress Recovery & Resilience

• Short bursts of tasks at school with rewards

• Eye spy games

• Rupture and repair with grandmother

• Ongoing volunteer commitment to family

• Minimizing transitions

• Vestibular and proprioceptive input

• Promoting Mom’s ongoing connection in her son’s life

• Undershooting his verbal production

• Highly structured, routine‐oriented classroom

• One item of food at a time, in small bites

Toolkits for Mom & Child for Stress Recovery & Resilience

• Mom’s sobriety

• Three recesses a day

• High, joyful affect

• Good sleep cycle

• Crawling and yoga ball exercises

• Language enriched, special education classroom

• Processing mom’s losses

• Use of action verbs with gestures

• Neurologist ruled out FASD


Regulation Factors

• Mom’s sobriety

• Neurologist ruled out FASD

• Healthy sleep cycle

Sensory Factors

• Eye spy games

• Minimizing transitions

• Vestibular & proprioceptive input

• Undershooting his verbal production

• Three recesses a day

• Crawling & yoga ball exercises

• Language enriched, special education classes

• Use of action verbs with gestures

• One item of food at a time, in small bites


Relevance Factors

• Short bursts of tasks at school with rewards

• Rupture & repair with grandmother

• Ongoing volunteer commitment to family

• Promoting Mom’s ongoing connection in her son’s life

• High joyful affect for child

• Processing Mom’s losses

Executive Factors

• Language enriched, special education classroom

• Highly structured, routine‐oriented classroom

• Short bursts of tasks atschool with rewards



Building a Cross‐Sector Community

•LAUSD, Special Ed

•EARLY HEAD START

Early Care & Education

•Infant Mental

Health Therapist

Request CPP

•FASD Pediatrician

• Developmental

Pediatrician

•Neurologist, CHLA

•South LA RegionalCenter

Speech Therapy

Occupational Therapy

Developmental Disabilities

Mental Health

Basic Needs/Medical

Step #3 ‐Four Brain Systems: Macro & Micro Levels

EXECUTIVE

RELEV

ANCE

REG

ULATIO

N

SENSORY

Lillas & Turnbull, 2009

Child WelfareFoster Care, 7 months

Young Children in Care(YCIC)

• The role of Birth to Five Champions, Two DCFS Administrators trained in IMH – Laura Andrade

– Charisse Pilar

• Eight Service Planning Areas (SPA)

4 hour trainings at each SPA

Multiple trainers, Train the Trainers

Once a quarter NRF case mapping

• Changing our Child Welfare culture!

8 Service Planning Areas (SPA’s)

Avisionaryseeslightinthedark…• Small, volunteer efforts provide a light

• If you are visionary, how can you help spread the light?

Molly Hahn, 2015

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