Transcript Starting with the Science THE ROLE OF RESEARCH IN

CONNECTING THE DOTS:
Safety, Permanency, and
Well-being
Bryan Samuels, Executive Director
Chapin Hall Center for Children
University of Chicago
-20.0%
-40.0%
-60.0%
60.0%
40.0%
0.0%
-80.0%
Data Source: Adoption and Foster Care Analysis and Reporting System, U.S. Department of Health and Human Services
South Dakota
Idaho
Iowa
Arkansas
Indiana
Utah
Mississippi
West Virginia
Texas
Nevada
Louisiana
20.0%
Oklahoma
Kansas
Delaware
Wyoming
Oregon
Kentucky
Washington
New Mexico
Maine
Hawaii
Maryland
Puerto Rico
DC
New Jersey
Ohio
New Hampshire
Georgia
California
New York
Florida
Minnesota
Vermont
Pennsylvania
Virginia
Massachusetts
Colorado
Michigan
Illinois
Wisconsin
Rhode Island
South Carolina
Missouri
Tennessee
Connecticut
Alaska
North Dakota
Nebraska
Alabama
North Carolina
Montana
80.0%
Arizona
25% Decline in Caseloads 2002-2011
100.0%
Average Lifetime Cost of Maltreatment is
$210,000
$144,360
$32,648
$6,747
$7,728
$7,999
Criminal justice Child welfare
Special
costs
costs
education costs
X. Fang et al., 2012
$10,530
Long-term
health care
costs
Short-term
health care
costs
Productivity
losses
Factors Contributing to Poor Outcomes
Stress
Genetics
Dysfunctional
Family
Environmental
Infections
Biological
Adverse
Childhood
Experiences
Substance
Abuse
Community
Violence
Prenatal
Damage
Abuse
Psychological
Trauma
Neglect
Understanding Adverse Childhood
Experiences
• The landmark study of
Adverse Childhood
Experiences (ACEs)
links negative early
experiences to poor
physical health
outcomes, including
obesity, heart disease,
stroke, cancer, liver
disease, etc.
• There is a linear
relationship between
the number of ACEs
experienced and the
likelihood of poor
health outcomes.
Emotional, and Social Capacities Are
Inextricably Intertwined Within the
Architecture of the Brain
Maltreatment during early
childhood can cause vital
regions of the brain that
lead to a variety of
physical, emotional,
cognitive, and mental health
problems.
Maltreatment results in
difficulties regulating
emotional reactions,
rage, dissociation,
changes in perception of
self and others, and
changes in understanding
and interpreting events.
i. Siegel, DJ. (2001). Toward an interpersonal neurobiology of the developing mind: Attachment relationships, “mindsight,” and neural integration. Infant Mental Health. 22(1-2):67.
ii. Terr, LC. (1991). Acute responses to external events and Posttraumatic stress disorders. In Lewis, M (Ed.). Child and adolescent psychiatry: a comprehensive textbook New Haven, CT: Williams &
Wilkins.
Maltreatment is powerful in shaping brain
architecture and actually changes the
chemistry in brain cells.
Maltreatment & Complex Trauma
• Refers to children’s experiences of multiple traumatic events that
occur within the caregiving system – the social environment
that is supposed to be the source of safety and stability in a child’s life.
• Typically, complex trauma exposure refers to the simultaneous or
sequential occurrences of child maltreatment—including
emotional abuse and neglect, sexual abuse, physical abuse, and witnessing
domestic violence—that are chronic and begin in early
childhood.
• Moreover, the initial traumatic experiences (e.g., parental neglect and
emotional abuse) and the resulting emotional dysregulation, loss of a safe
base, loss of direction, and inability to detect or respond to danger cues,
often lead to subsequent trauma exposure (e.g., physical and
sexual abuse, or community violence).”
Impact of Trauma on Brain
Development
Traumatic
Stress
NEUTRAL
START
Adapted from: Family
Policy Council. (2007).
The High Cost of
Adverse Childhood
Experiences (PPT).
Olympia, WA: Author.
BRAIN
Hormones,
chemicals, and
cellular systems
prepare for a
tough life
INDIVIDUAL
> Edgy
> Hot temper
> Hyper
vigilant
> “Brawn over
brains”
OUTCOME
Individual and
species survive
the worst
conditions
BRAIN
Hormones,
chemicals, and
cellular systems
prepare for life in
a benevolent
world
INDIVIDUAL
> Laid back
> Relationshiporiented
> Think things
through
> “Process over
power”
OUTCOME
Individual and
species live
peacefully in good
times; vulnerable
in poor conditions
Connecting the Dots to Stress at
Home
History of domestic violence against
caregiver
History of abuse or neglect of primary
caregiver
Primary caregiver had serious mental
health problem
Active domestic violence against
caregiver
Active drug abuse by primary
caregiver
Active alcohol abuse by primary
caregiver
Child Placed Out of Home
Child Remained in Home
0
10
20
30
40
Connecting the Dots to Stress at
Home
Prior reports of child maltreatment
High stress on the family
Low social support
Family had trouble paying for basic necessities
Child had major special needs or behavioral
problems
Primary caregiver had poor parenting skills
Parent had unreal expectations of child
Primary caregiver used inappropriate or
excessive discipline
Primary caregiver described or act toward
child in predominately negative terms
Child Placed Out of Home
Child Remained in Home
0
10
20
30
40
Percent
50
60
70
80
Connecting the Dots of Early Experiences
Alter Gene Expression
Extensive scientific
research has shown
that the healthy
development
depends on how
much and when
certain genes are
expressed in the
cells of these
systems.
Research has shown
that environmental
factors and early
experiences have the
power to impact
whether genes are
turned "on" or
"off"—essentially
whether and when
genes are activated
to do certain tasks.
Connecting the Dots to Poor Outcomes
Among Children Known to Child Welfare
In-Home, Connected to Services
Out-of-Home
In-Home, Not Connected to Services
45%
40%
37% 38%
41%
31%
24%
24%
20% 19%
18%
Developmental
Problems
(0-5 years-old)
Cognitive Problems
(4-17 years-old)
24%
Emotional/Behavioral Substance Use Disorder
Problems
(11-17 years-old)
(1.5-17 years-old)
Dolan, M., Casanueva, C., Smith, K., & Ringeisen, H. (2011). NSCAW Child Well-Being Spotlight: Children Placed Outside the Home and Children Who Remain In-Home after a
Maltreatment Investigation Have Similar and Extensive Service Needs. OPRE Report #2012-32, Washington, DC: Office of Planning, Research and Evaluation, Administration
for Children and Families, U.S. Department of Health and Human Services.
Connecting the Dots to Relational Skills
and Social-Emotional Problems
Social Skills Problems
Emotional Problems
43%
41%
34%
In Home
33%
43%
36%
Kinship Care
Foster care
“There is no doubt that children in harm’s way should be
removed from a dangerous situation. However, simply moving a
child out of immediate danger does not in itself reverse or
eliminate the way that he or she has learned to be fearful. The
child’s memory retains those learned links, and such thoughts
and memories are sufficient to elicit ongoing fear and make a
child anxious.”
National Scientific Council on the Developing Child (2010). Persistent Fear and Anxiety Can Affect Young Children’s Learning and Development: Working Paper No. 9.
Retrieved fromwww.developingchild.harvard.edu (emphasis added)
“Traditional child welfare approaches to maltreatment focus
largely on physical injury, the relative risk of recurrent harm,
and questions of child custody, in conjunction with a criminal
justice orientation. In contrast, when viewed through a child
development lens, the abuse or neglect of young children should
be evaluated and treated as a matter of child health and
development within the context of a family relationship crisis,
which requires sophisticated expertise in both early childhood
and adult mental health.”
National Scientific Council on the Developing Child (2004). Young Children Develop in an Environment of Relationships: Working Paper No. 1. Retrieved
from www.developingchild.harvard.edu (emphasis added)
Safety & Permanency are Necessary but
not Sufficient to Ensure Well-Being
REUNIFICATION
KINSHIP CARE
• “Children who went
home and stayed home
had a four fold increase
in internalizing
behavior problems
from baseline to 18month follow-up.
Though the percentage
of children with
behavior problems at
36-month follow-up
decreased, still twice as
many children met or
exceeded clinical levels
as compared to
baseline” (1).
• “Kinship placements
were not predictive of
mental health
outcomes regardless of
the amount of time in
kinship care. …
[M]multiple causes of
mental health problems
often occur previous to
placement in care and
may not be mediated by
the child’s foster care
experience enough to
show significant
differences” (2).
1.
2.
3.
ADOPTION
• In assessments of
children at 2, 4, and 8
years following
adoption, “Adopted
foster youth were
more behaviorally
impaired than their
non-FC counterparts,
although a striking
number of non-FC
youth displayed
behavior problems as
well” (3)
Bellamy, J. (2008). Behavioral problems following reunification of children in long-term foster care. Children and Youth Services Review. 30:216.
Fechter-Leggett, MO & O’Brien, K. (2010). The effects of kinship care on adult mental heath outcomes of alumni of foster care. Children and Youth Services Review. 32(2):206.
Simmel, C.; et al. (2007). Adopted youths psychosocial functioning: A longitudinal perspective. Child and Family Social Work. 12(4):336.
Chaffee Programs Yield Poor Outcomes
Chaffee Foster Care
Independence
Program Type
Outcomes Measures
Findings
Tutoring and
Mentoring
Age percentile in reading and math, school grades, high school
completion, highest grade completed, and school behavior problems
No statistically significant difference
on key outcomes
Life Skills Training
High school completion, current employment, earnings, net worth,
economic hardship, receipt of financial assistance, residential
instability, homelessness, delinquency, pregnancy, possession of
personal documents, any bank account, and sense of preparedness
in 18 areas of adult living
No statistically significant difference
on key outcomes
Employment
High school completion, college attendance, current employment,
earnings, net worth, economic hardship, receipt of financial
assistance, residential instability, homelessness, delinquency,
pregnancy, possession of personal documents, any bank account,
and sense of preparedness in 18 areas of adult living
No statistically significant difference
on key outcomes
Intensive Case
Management and
Mentoring
High school completion, college enrollment and persistence, current
employment, employment past year, earnings, net worth, economic
hardship, receipt of financial assistance, residential instability,
homelessness, delinquency, pregnancy, possession of personal
documents, any bank account, and sense of preparedness in 18 areas
of adult living
Higher rates of college attendance
and persistence among treatment than
control group youth but difference
was largely explained by continued
child welfare system involvement
among youth in the treatment group
Koball, Heather, et al. (2011). Synthesis of Research and Resources to Support At-Risk Youth, OPRE Report # OPRE 2011-22, Washington, DC: Office of Planning, Research and Evaluation, Administration for
Children and Families, U.S. Department of Health and Human Services.
Pathway to Poor Outcomes
for Children and Youth
Abusive or
Neglectful
Parenting
Insecure
Attachments &
Emotional
Dysregulation
Poor Social
Functioning,
Disturbed Peer
Relationships
Maladaptive
Coping
Strategies
Psychological
Distress
Poor
Outcomes
Connecting the Dots to Executive Function
Executive function and self-regulation skills successfully, both individuals and
society experience lifelong benefits.
• School Achievement—Executive function skills help children remember and follow
multi-step instructions, avoid distractions, control rash responses, adjust when rules
change, persist at problem solving, and manage long-term assignments.
• Positive Behaviors—Executive functions help children develop skills of teamwork,
leadership, decision-making, working toward goals, critical thinking, adaptability, and
being aware of our own emotions as well as those of others.
• Good Health—Executive function skills help people make more positive choices
about nutrition and exercise; to resist pressure to take risks, try drugs, or have
unprotected sex; and to be more conscious of safety for ourselves and our children.
Having good executive function primes our biological systems and coping skills to
respond well to stress.
• Successful Work—Executive function skills increase our potential for economic
success because we are better organized, able to solve problems that require planning,
and prepared to adjust to changing circumstances.
Integrating Safety, Permanency, and Wellbeing
The framework identifies four basic domains of well being: (a) cognitive functioning, (b)
physical health and development, (c) behavioral/emotional functioning, and (d) social
functioning. Within each domain, the characteristics of healthy functioning related directly
to how children and youth navigate their daily lives: how they engage in relationships, cope
with challenges, and handle responsibilities.
Cognitive
Functioning
Environmental
Supports
Emotional/
Behavioral
Functioning
Physical Health
and
Development
Personal
Characteristics
Social
Functioning
Developmental Stage
4/8/2013
20
Screening, Functional Assessment &
Progress Monitoring
• “Functional assessment—assessment of multiple aspects of
a child’s social-emotional functioning (Bracken, Keith, &
Walker, 1998)—involves sets of measures that account for
the major domains of well-being.”
• “Child welfare systems often use assessment as a point-intime diagnostic activity to determine if a child has a
particular set of symptoms or requires a specific
intervention. Functional assessment, however, can be
used to measure improvement in skill and competencies
that contribute to well-being and allows for on-going
monitoring of children’s progress towards functional
outcomes.”
• “Rather than using a “one size fits all” assessment for
children and youth in foster care, systems serving children
receiving child welfare services should have an array of
assessment tools available. This allows systems to
appropriately evaluate functioning across the domains of
social-emotional well-being for children across age groups
(O’Brien, 2011) and accounting for the trauma- and mental
health-related challenges faced by children and youth who
have experienced abuse or neglect.”
May 11, 2012
Two Days in May - Ohio
Valid and reliable mental and
behavioral health and
developmental screening and
assessment tools should be used
to understand the impact of
maltreatment on vulnerable children
and youth.
TRAUMA SCREENING
•
•
•
Child and Adolescent Needs and
Strengths (CANS) Trauma Version
Childhood Trauma Questionnaire (CTQ)
Pediatric Emotional Distress Scale
(PEDS)
FUNCTIONAL ASSESSMENT
•
•
•
Strengths and Difficulties Questionnaire
(SDQ)
Child Behavior Checklist (CBCL), the
Social Skills Rating Scale (SSRS)
Emotional Quotient Inventory Youth
Version (EQ-i:YV)
21
Time to Stop Counting Service
“It is common for child welfare systems to gauge their success based on whether or not
services are being delivered. One way to focus attention on well-being is to measure
how young people are doing behaviorally, socially, and emotionally and track whether or
not they are improving in these areas as they receive services” (ACYF-CB-IM-12-04).
Measuring Services
How many children received…?
How many hours of training were delivered?
What percent of children got…?
Measuring Outcomes
Are trauma symptoms reduced?
Did services increase relationship skills?
Do children have healthier coping strategies?
De-Scaling What Doesn’t Work, Scaling
Up What Does
De-scaling
what doesn’t
work
Parenting Classes
Trauma Screening
Generic Independent
Living Skills Training
EvidenceBased/Informed Mental
Health & Parenting
Interventions
Generic Counseling
Functional Assessment
INEFFECTIVE
APPROACHES
RESEARCH-BASED
APPROACHES
Investing
in what
does
Intervention Must be Strong Enough to
Meet Complex Profiles
Pre-treatment
Post-treatment
Number of symptoms
9
8
7
**
6
5
4
*
3
**
2
1
*
0
PTSD
MDD
SAD
ADHD
ODD
*p<.001, **p<.0001
Scheeringa, M. and Gonzales, R.. Clinical treatment approaches to trauma. Tulane University School of
Medicine. (April 15, 2013 presentation to at the CWLA Neuroscience and Child Maltreatment
Conference).
4/25/2013
24
Matching Populations, Outcomes, &
Approaches: IV-E Waiver Examples
Population
Screening
& Assessment
EBIs
Outcomes
Children, 8-17
- UCLA PTSD Index
- Strengths & Difficulties
Questionnaire
- Child & Adolescent
Needs & Strengths
Trauma-Focused
Cognitive Behavioral
Therapy
- Behavior problems
- PTS symptoms
- Depression
Children, 13-17
- Strengths & Difficulties
Questionnaire
- Child & Adolescent Needs
& Strengths
Multisystemic Therapy
- Delinquency/Drugs
- Peer problems
- Family cohesion
Children, 2-7
- Trauma Symptoms
Checklist for Young Children
- Infant Toddler Emotional
Assessment
- CBCL
Parent-Child Interaction
Therapy
- Conduct disorders
- Parent distress
- Parent-child interaction
Connecting the Dots to Child Welfare Practices
Maltreatment investigation and removal
Monthly caseworker visits
Training, monitoring, retention of foster parents
Case plan development and progress monitoring
Concurrent planning, and termination of parental rights
Sibling placement and connections
Pre/post adoption and guardianship placement protocols
Reunification, return home, and transition supports
Case/transition planning for youth aging out of care
Case coordination with other service systems
Placement disruptions, dissolutions or (un)anticipated moves
Connecting the Dots of Promising Practices
To promote emotional, social, cognitive, and physical development broadly,
promising practices including a range of strength building strategies that:
1.
2.
3.
4.
5.
Reduce stress in children’s lives, both by addressing its source and
helping them learn how to cope with it in the company of competent,
calming adults;
Foster social connection and open-ended creative play, supported by
adults;
Incorporate vigorous physical exercise into daily activities, which
has been shown to positively affect stress levels, social skills, and brain
development;
Increase the complexity of skills step-by-step by finding each child’s
“zone” of being challenged but not frustrated; and
Include repeated practice of skills over time by setting up
opportunities for children to learn in the presence of supportive
mentors and peers.
Connecting Dots of Promising Practices
Focus on Relationships—Children develop in an environment of
relationships. This starts in the home and extends to caregivers, teachers,
medical and human services professionals, foster parents, and peers.
Children are more likely to build effective executive function skills if the
important adults in their lives are able to:
1. Support their efforts;
2. Model the skills;
3. Engage in activities in which they practice the skills;
4. Provide a consistent, reliable presence that young children can trust;
5. Guide them from complete dependence on adults to gradual
independence; and
6. Protect them from chaos, violence, and chronic adversity, because
toxic stress caused by these environments disrupts the brain circuits
required for executive functioning and triggers impulsive, “act-nowthink-later” behavior.
Connecting the Dots To Well-being
Focus on child &
family behavior,
skills competencies,
outcomes
Monitor progress for
improved
child/youth
functioning
Build capacity for
more intensive
EBP/RBIs
Promoting
Well-being
Actively promote
healthy relationships
Change practice to
address trauma
Take developmental
approaches
PROMOTING WELL-BEING ACROSS THE U.S.
Regional Partnership Grants to Increase Well-Being and Improve
Permanency Outcomes for Children Affected by Substance
Abuse
Partnerships to Demonstrate the Effectiveness of Supportive
Housing for Families in the Child Welfare System
Title IV-E Child Welfare Demonstration Projects, Approved in
FY 2012
Working with Children’s Bureau for Title IV-E Child Welfare
Demonstration Projects, for FY 2013
6/3/2013
Permanency Innovations
Initiative
30
Illinois’ Child Welfare Population 1990 to
2003
60,000
51,000
50,000
40,000
30,000
20,848
23,400
20,000
10,000
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Re-Defining Success: Focusing on
Well-being
1. Redesign performance-based contracting to emphasize
well-being outcomes in addition to permanency.
2. Implement new placement system to keep children in the
same school they attended prior to substitute care.
3. Implement comprehensive assessment.
4. Re-design transitional living and independent living
programs to prepare youth for transition to adulthood.
5. Creat a child location unit that tracks all youth who run
away.
6. Introduce evidence-based services to address trauma.
7. Establish a common outcome measures for residential
treatment and group homes.
RE-DEFINING SUCCESS: STATE OF
ILLINIOS
• Reduced caseload ratios in public and private sectors form
20 cases per worker to 14 cases per worker.
• Reduced disproportionate representation of African
American children in child welfare system declined from
69.3% to 60%.
• Decreased number of youth “on run” decreased by 40% and
number of days “on run” decreased by 50%.
• Decreased late child protection investigations by 60%.
• Reduced distance between home of origin and foster care
placement reduced from 20 miles to 7.8 using new school
placement strategy.
• Reduced time in residential treatment by 20%.
• Decreased child welfare population declined from 23,500
to16,500 statewide.
QUESTIONS?
SOCIAL AND
EMOTIONAL WELLBEING
FOR CHILDREN,
YOUTH,
AND FAMILIES
Healing and Recovery
Intensive
Intervention
Assessment drives individualized treatment plan with
evidence-based interventions
Targeted Social and
Emotional Supports
Systematic approaches to teaching coping
skills and social skills
Stress Reducing and
Developmentally Appropriate
Environments
Safe, Supportive, and Responsive
Relationships
Knowledgeable and Effective Workforce
Adapted from the Technical Assistance Center on Social Emotional Intervention for Children and the Center on the
Social and Emotional Foundations for Early Learning
Nurturing environments provide
security and promote positive
outcomes
Supportive, responsive
relationships promote
healing and recovery and
reinforce growing social and
emotional skills
Systems and policies promote and sustain
screening, assessment, the use of evidencebased interventions, progress monitoring,
and continuous quality improvement
4/30/2013
35
Achieving Better Outcomes
context: therapeutic, responsive & supportive settings &
relationships
Validated
Screening
Clinical
Assessment
Functional
Assessment
Case Planning
for Safety,
Permanency,
and Well-being
Evidencebased/informed
Intervention(s)
Progress Monitoring
social-emotional functioning
Outcomes:
Safety,
Permanency,
Well-Being
Evidence-Based Interventions
Diagnosis/Concern/Activity
Evidence-Based Interventions (Examples)
Age
Identification of Mental Health
& Behavioral Health Issues
SCREENING
TOOLS
Screening Activities
•
•
•
•
Child & Adolescent Needs & Strengths—Trauma (CANS)
Pediatric Symptom Checklist (PSC)
Strengths and Difficulties Questionnaire (SDQ)
Child Behavior Checklist (CBCL)
0-18
4-16
4-17
4-18
Most Common Mental Health Diagnoses for Children in Foster Care (bold red text indicates parent or caregiver component)
Conduct
Disorder/Oppositional Defiant
Disorder
•
•
•
•
•
•
•
Attention Deficit Hyperactivity
Disorder
• Parent–Child Interaction Therapy (PCIT)
• Triple P
• Children’s Summer Treatment Program (STP)
2-7
0-16
6-12
Major Depression
• Adolescents Coping with Depression (CWD-A)
• Cognitive Behavioral Therapy (CBT) for Adolescent Depression
• Alternative for Families-Cognitive Behavioral Therapy (AF-CBT)
13-17
13-25
4-16
Parent-Child Interaction Therapy (PCIT)
Strengthening Families Program (SFP)
Early Risers – Skills for Success
Brief Strategic Family Therapy (BSFT)
Multisystemic Therapy (MST)
Familias Unidas
Multidimensional Treatment Foster Care (MTFC)
2-7
3-16
6-12
6-17
9-17
12-17
12-17
Evidence-Based Interventions
Diagnosis/Concern/Activity
Evidence-Based Interventions (Examples)
Age
• Child-Parent Psychotherapy (CPP)
• Parent-Child Interaction Therapy (PCIT)
• Combined Parent-Child Cognitive Behavioral Therapy for
Families at Risk for Child Physical Abuse (CPC-CBT)
• Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
• Alternatives for Families/Abuse Focused Cognitive Behavioral
Therapy (AF-CBT)
• Cognitive Behavioral Intervention for Trauma in Schools (CBITS)
• Trauma Affect Regulation: Guide for Education and Therapy
(TARGET-A)
• Structured Psychotherapy for Adolescents Responding to Chronic Stress
(SPARCS)
• Prolonged Exposure (PE) Therapy for Youth 18-25
0-6
2-17
3-17
•
•
•
•
•
•
•
•
•
0-6
0-12
0-12
0-16
0-17
6-12
6-17
9-11
10-18
Trauma
Actionable Trauma Symptoms
 Posttraumatic Stress
Disorder
4-55
5-17
6-12
10-55
13-21
18-25
Behavioral Concerns
Internalizing/Externalizing
Behaviors
 Behavioral Problems
and Relational
Concerns
Child Parent Psychotherapy (CPP)
Promoting Alternative Thinking Strategies (PATHS)
Incredible Years
Triple P
Parenting Wisely
Nurturing Parenting Programs (NPP)
Brief Strategic Family Therapy (BSFT)
Fostering Healthy Futures (FHF) – mentoring + skills training
Functional Family Therapy (FFT)
Connecting the Dots to Brain Science
• While the healthy body can restore itself quickly after a stressful
incident (running for a late bus, facing an important examination), this
is not the case with long term stress overload.
• Chronic (toxic) stress causes the brain to secrete an excess of
hormones, such as cortisol. Excessive secretion of cortisol interferes
with memory, retention, focus, and learning.
• As a result of experiencing extreme traumatic stress over time, the part
of the brain responsible for learning new things—can become
damaged.
• An overload of stress can cause an imbalance in the functioning of
the brain’s hemispheres.
• When we are excessively depressed, anxious, and stressed, the right
hemisphere becomes dominant. This interferes with cognition, selfregulation, and the ability to focus and remember.
7/20/11
IL CFP Early Childhood
39