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ABOUT THE NEURORELATIONAL FRAMEWORK

What is the NRF (NeuroRelational Framework)?

Neuro = references the focus on understanding principles of brain development

Relational = references the significance of relationships and their impact on healing

Framework = references the NRF as both an assessment and intervention practice, as well as a map that guides the use of promising and evidence-based practices, so that treatments can be better matched to the neurodevelopmental needs of the child and parents.

What is the ‘NRF Global Communities’ and Mission?

In June, 2016, a non-profit was birthed as a place to “house” the NRF and the communities using it as a common language and a shared approach. Our new “home” is at www.nrfgc.com

Mission: This non-profit offers dynamic educational training to cross-disciplined communities with at-risk infants, young children, and families, based upon the use of the Neurorelational Framework (NRF). The NRF is a translational framework, translating brain science into clinical practice. Our passion is to train national and international communities that have high-risk infants, in particular – pregnancy to five-year-olds and their caregivers in trauma-informed and neurobiologically sensitive developmental care. Integrated into the curriculum, is support for practitioners furthering a cultural awareness of themselves and their families as cultural beings. To promote sustainability and systems change, we specialize in training and transforming communities. We prioritize servicing low-income, complex, and underserved populations. In addition, this non-profit is pursuing scientific research that assesses the outcomes of the child, families, providers, and communities using the NRF.

What are the NRF Three Steps?

The three NRF steps are organized around the metaphor of a tree:

• Step One. The roots to the tree are our 24-hour sleep-awake cycle that orients us towards bodily health and basic regulation. The “green zone” is the calm, alert state that gives us the most access to all of our brain networks for optimal functioning and is the basis for long term health outcomes. As part of the 24 hour cycle the NRF assesses one’s ability to flexibility adapt to environmental demands with stress responses and discerns between adaptive and toxic stress.

• Step Two. With good sleep and green zone in the root system of the tree, we have opportunities to build healthy relationships. The trunk represents the relational health of the tree which grows through the “serve and return” process of back and forth engagement with the ability to create shared joy between a caregiver and child.

• Step Three. The branches of the tree represent the health of the brain networks. If there are deep and strong roots, there is a greater chance the trunk of the tree will grow well, with the branches of the tree becoming lush and networked. Similarly, we seek to build healthy brain architecture off of a strong regulation system supported by healthy relationships.

What does the NRF look like at the systems level?

Mapping from the four brain systems to the level of the community and systems of care allows for more integrated, cross-sectored work.

• Regulation system= meeting basic needs and providing medical care

• Sensory system = meeting developmental needs and addressing delays or disabilities

• Relevance system = meeting socio-emotional, relational, and mental health needs

• Executive system = meeting early care, learning and educational needs

• Child Welfare is placed in the center of the wheel, as an example, because these children in care often have very complex needs, often engaging in each system of care. Children with Autism and other complex neurodevelopmental disorders are equally engaging multiple systems of care and could be placed in the center of this wheel.

Why develop the NRF?

As a professional:

As professionals, we are trying to serve many individuals with complex needs – high levels of trauma, developmental delays and disabilities and medical challenges. Complex needs require complex and integrated solutions. However, families often encounter simplistic solutions that are only sometimes connected to each other. Existing models are typically limited and tend to focus on eliminating problem behaviors. We developed the NRF to embrace complexity in the individual, family, community and systems of care.

As a parent:

I was also motivated to develop the NRF based upon my own experiences parenting an inconsolable baby for the first few years of his life. I went from practitioner to practitioner, and each of them was helpful, yet only saw the cause of my baby’s distress through his or her lens. Each of them thought they were the whole pie instead of a piece of the pie. After running around, exhausted, I finally realized each professional was “right”! And, at the same time – “wrong” because no one talked to the other providers nor had a big picture to offer. The NRF is a solution to that problem – a common language and shared approach that is interdisciplinary (whole pie) in its focus, something that each professional touching the life of a baby, young child, or even older youth, and his parents can use.

How did you develop the NRF?

First, we developed the textbook. My co-author is a pediatric neuropsychologist and she represents the “neuro” part of this work. She’s the one that really took neuroscience literature, with a focus on the early years, and condensed it into the four brain systems. I brought the “relational” focus, within a developmental context, to this work. The integration of the two authors’ strengths resulted in the book being named the “neuro-relational” framework.

I then built on this work to develop the three NRF steps to move this from the theoretical to the daily practice of providers. These three steps form the core of the NRF provider manual which can be found at www.nrfgc.com.

What is the NRF’s value-add?

At the Individual and family level:

• Intensifies the focus on eliminating toxic stress patterns which has positive long-term health consequences

• Intensifies the focus on the high quality “serve and return” process which improves brain networks

• Intensifies the capacity to look for multiple causes of toxic stress patterns rather than narrowing the variables

• Increases the early identification of developmental delays and disabilities, getting development back on track as quickly as possible

• Improves the neurodevelopmental matching of treatment modalities to the needs of the child and family

• Increased awareness of neurodevelopment guides practitioners to see 1) where to begin treatment and 2) whether developmental progress is being made or not

At the Agency level:

• Increases practitioner capacity via shared knowledge

• Increases the use of reflective practice

• Increases the integration of neuroscience into practice

• Increases the cross-integration of programs or services within an agency

• Increases provider understanding of the interplay between toxic stress, cultural, and power-differentials on personal, interpersonal and institutional levels

At the Systems level:

• Increases integration across agencies and service delivery systems

• Increases coordination while reducing fragmentation and duplication

• Increases the system’s capacity to ameliorate the impact of toxic stress by promoting integrated care, trauma-informed care, and care that addresses adverse childhood experiences

• Improves the targeting of interventions at the community level and the integration of Evidence Based Treatment’s across systems of care

What are current cohort participants saying about the NRF?

Alaska Cohort Quotes from the Early Intervention Sector:

• “I like how [the NRF] can lend itself to a variety of models and schools of thought. For example, I can look at a curriculum and the NRF helps me determine what its strengths and weaknesses are. Additionally, I can look at a family system and see the same elements. I would like to use the NRF model with Child Welfare more, both to explain children’s needs, especially social/emotional, but also to support them in a reflective way as they deal with some very difficult situations.”

• “The Neurorelational Framework is changing my professional practice in a positive, functional way. The 4 systems: Regulation, Sensory, Relevance, and Executive, are an organized way for me to reflect on a child, a caregiver, a dyad, or even an entire system. As a smaller-picture type of person (in nature and in training), this is stretching my ability to look at the “big picture.” ...I am starting to see how little changes and relationships can make a big difference.”

Goals and Aspirations from Other Cohorts for Families, Providers, and Systems

Families

• Increased skills for working with families/parents and children

• Increased staff respect for the child’s individual experience

• Increased coordination of care for families

Providers

• Increased understanding of IMH/trauma/toxic stress

• Increased trauma-informed knowledge & practice

• Increased awareness of connections and understanding of others roles

• Increased use of assessment and intervention processes that accommodate complexity

Systems

• Systems would provide time and resources to support collaboration, knowledge sharing, and professional development

• Training, service delivery, and public policy would support shared competencies and language across disciplines while respecting individual differences

• Policies and systems ranging from research to intervention would embrace complexity

• Public and private funders would increase pooling of resources to ensure comprehensive and integrated service delivery communities with integrated care as the expected best practice

• Improve effectiveness and efficiency across systems in serving children and families with high needs

• There would be widespread use of Reflective Practice across all systems of care and disciplinary boundaries

What is the theoretical basis for the NRF?

• Brain development research and contemporary neuroscience theories (e.g., allodynamic regulation, embodied cognition)

• Developmental principles (e.g., Vygotsky, Bronfenbrenner)

• Infant mental health relationship-based practice that focuses on caregiver-child relationships as the focal point for all interventions (e.g., DIR/Floortime, Circle of Security, Child Parent Psychotherapy, Interactive Guidance)

• Reflective Practice and Supervision: (e.g., http://infantcrier.mi-aimh.org/reflective-supervisionconsultation-what-is-it-why-does-it-matter/)

• Equity and Social Justice: (e.g., https://imhdivtenets.org/tenets/; http://visions-inc.org/) • A focus on Evidence-Based Practice as distinct from Evidence-Based Treatments (Institute of Medicine)

• Federally funded recent shifts in research thinking: (e.g., NIH Research Domain Criteria, Systems Science Models, Interdisciplinary Research, Community-Based Participatory Research)

How is the NRF being researched and evaluated?

Moving with Research Trends:

The NRF is responsive to current national shifts and aligns with changes made by the National Institute of Health and National Institute of Mental Health.

The NRF Global Communities are working with Dr. Nathaniel Osgood at the University of Saskatchewan, using an MIT Empatica E4 watch to collect physiological data from parents and children (dyads) in real-world, real-time settings.

• The NRF research team is building a NRF phone app that will track:

o Physiological markers for internal stress signals

o Identification of external stress signals

o The occurrence of stress triggers across brain networks

o Parents’ use of tools for stress recovery

o This data will include children in a birth to five range with their parents from a range of low-risk to high-risk dyads.

Evaluation data in NRF communities (Alaska, Edmonton, Alberta/Canada, Central Valley California, Wisconsin, & Seattle)

• Pre and post knowledge domains

• Pre and post personal experiences with the trainings

• Social network analysis (SNA)

o Most communities are engaging in social network analysis. This allows us to visually map the expanding ring of connections that practitioners form within and outside each NRF community. SNA shows the impact of the NRF not just on the individual who participated, but on the agencies they serve and the systems they operate in. The SNA allows us to map the effects on and beyond the people who have been trained. A journal article is being prepared about the Alaska SNA outcomes.

Current NRF Grants and Contracts

• Grant: Alaska NRF Community, Infant Learning Program State Programs. A two year training cohort is now complete. Proposal is being submitted for beginning Cohort #2 being to AK State in Conjunction with Alaska’s Part C State Systemic Improvement Project focused on Socio-Emotional Competencies in August, 2016.

• Grant: Central Valley California, a two year project with two cohorts trained back to back from 2014 to 2016 with all five sectors. Several of the agencies will continue to work together sharing cases in 2017.

• Grant: Wisconsin Early Childhood Comprehensive Systems grant. One year grant that trained a cross-sector cohort whose outcome became to transform a Drug Court Team into a Healthy Infant Court Team.

• Grant: Seattle King County, a two year grant training two cross-sector cohorts.

• Contract: NRF Global Communities Contract with Department of Child and Family Services, Los Angeles. 4 hour training on Brain Development and the NRF’s Three Clinical Steps with a NRF Court Team Case integrated. Mandatory training for all of Los Angeles County’s Social Workers and Community Liaisons.

References related to the NRF:

Barnes-Najor, J. V., Brown, R. E., Doberneck, D., Fitzgerald, H. E., & McNall, M. A. (2015). Systemic Engagement: Universities as Partners in Systemic Approaches to Community Change. Journal of Higher Education Outreach and Engagement, 19, 1-21.

Brandt, K., Diel, J., Feder, J., & Lillas, C. (2012). A Problem In Our Field: Making Distinctions Between Evidence-Based Treatment and Evidence-Based Practice As a Decision-Making Process. Zero To Three, March.

Crowley, K and Lillas, C. (in press, 2017). Improving Regulation Skills. S. Spitzer (Ed.). R. Watling, Autism: A Comprehensive Occupational Therapy Approach, 4th Edition. The American Occupational Therapy Association.

Delahooke, Mona. (in press). Relationships First: A Guidebook for Supporting Social-Emotional Development. Professional Education Systems, Inc. (PESI).

Kessler, Debra. (a parent book in process). Developing Self Awareness and Resilience in Daily Life: WHAT is in my Bucket?

Lillas, C. (2014). The Neurorelational Framework (NRF) in Infant and Early Childhood Mental Health. K. Brandt, B. Perry, S. Seligman, E. Tronick, Infant and Early Childhood Mental Health: Core Concepts and Clinical Applications. Arlington, Virginia: American Psychiatric Publishing.

Lillas, C., Feder, J., Diel, J., & Brandt, K. (2014). Weighing the Evidence: Evidence-Based Practice and Evidence-Based Treatments in Infant Mental Health. K. Brandt, B. Perry, S. Seligman, E. Tronick, Infant and Early Childhood Mental Health: Core Concepts and Clinical Applications. Arlington, Virginia: American Psychiatric Publishing.

Lillas, C. & Marchel, M.A. (2015). Moving Away from WEIRD: Systems-Based Shifts in Research, Diagnosis, and Clinical Practice. Perspectives in Infant Mental Health. Michigan: World Association for Infant Mental Health. Winter.

Lorrain, Brandene. (in press, 2017). Reflective Peer Consultation as an Intervention for Staff Support in NICU. Newborn and Infant Nursing Reviews. Elsevier.

Who is talking about the NRF?

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