Attachment-Focused Interventions:

Attachment-Focused Interventions:
ABC of Ohio presents… Attachment-Focused Interventions: Cultivating Nurturing Environments to Facilitate Parent-Child Attachment

Developmental Trauma Disorder
Part I Theoretical Rationale: Developmental Trauma Disorder (Complex Trauma or Reactive Attachment Disorder)

DEVELOPMENTAL TRAUMA DISORDER (Cook, Blaustein, Spinazzola and van der Kolk, 2003) Definition Children’s experience of multiple traumatic events that occur within the care giving system Prenatal exposure to drugs/alcohol Neglect/Institutionalization Abuse Abandonment/Multiple Moves Pain/Illness/Hospitalization Involves simultaneous or sequential occurrences of child maltreatment—that are chronic and begin in early childhood

DEVELOPMENTAL TRAUMA DISORDER (Cook, Blaustein, Spinazzola and van der Kolk, 2003)
Areas of Impairment Attachment Affect Regulation Dissociation Cognition Biology Behavioral Control Self Concept

ATTACHMENT Attachment is the process by which an emotional connection develops between an infant and his/her caretaker This process organizes the infant physiologically and psychologically Attachment becomes the basis for how he/she will relate to the world, learn and form relationships In addition to the basic needs such as food, shelter and clothing, the infant needs emotional care which is essential for his/her development Attachment grows through daily interactions between caretaker and infant Smiles, nurturing touch, eye contact, mutual play build trust and security in the child This first relationship becomes the blueprint for all future relationships It is also the origin of conscience development, empathy, self-esteem and cause and effect thinking Insecure attachment patterns seen in 80% of maltreated children 5

NEED ANGER HIGH AROUSAL RAGE TRUST GRATIFICATION 6

DISSOCIATION AFFECT REGULATION
Difficulty with emotional self-regulation Difficulty describing feelings and internal experience Problems knowing and describing internal states Difficulty communicating wishes and desires Predisposed to earlier onset of affective problems, which is associated with more episodes and poorer outcome Distinct alterations in states of consciousness Two or more distinct states of consciousness Hyperarousal & Dissociative Begins as a protective defense mechanism and then is utilized more frequently as trauma continues

Cognitive Problems with… Irrational cognitions
Sustained curiosity/initiative Processing new information Focusing and completing new tasks (hypervigilence vs. hyperactivity) Understanding own contribution to what happens to them (cause-and-effect thinking) Object constancy Orientation with time and space Learning disabilities Abstract thinking

Biology Experiences impact brain development
Problems with… Experiences impact brain development Lifelong reactivity to stress Problems with coordination, balance, body tone Somatization Analgesia (inability to feel pain) Hypersensitivity to physical touch Wide variety of medical problems: pelvic pain, asthma, skin problems, autoimmune disorders Sensory Integration Dysfunction

Behavioral Control Poor impulse control Self destructive behavior
Aggression Self soothing behaviors Sleep and eating disturbances Substance abuse Excessive compliance or oppositional behavior Reenactment of traumatic past

Self Concept Lack of coherent sense of self Disturbance of body image
Low self-esteem Poor sense of separateness

7 Core Issues The Adoption Overlay
Loss Grief Self-concept Identity Shame and Guilt Intimacy and Relationships Control

Translating Theory into Practice:
Part II Translating Theory into Practice: A Tool-Box of Techniques

Develop a Coherent Narrative
Treatment Principles Parent-Centered and Child-Focused Develop a Coherent Narrative

Treatment Principles Facilitate Grief Shock/Denial Bargaining
Depression/Sorrow Anger Resolution

Treatment Principles Encourage Emotional Regulation
(Decrease Dissociation and Hyperarousal) Encourage Behavioral Change

Treatment Principles Facilitate Developmental Gains Attachment
Affect Regulation Dissociation Cognitive Behavioral Control Self-concept Biology

Eye contact, Touch, Talking, Smells, Food, Motion, Warmth
Treatment Principles Nurture, humor and fun! Eye contact, Touch, Talking, Smells, Food, Motion, Warmth

A Tool-Box of Techniques
Timeline Life Book Children’s Books Journaling Art Role-plays Videos Music Theraplay™ Yoga Massage

The narrative is an emotionally rich story that makes sense of one’s life. Affirms reality Creates meaning, provides closure, reduces need to ruminate Organizes memories—implicit and explicit— into one chronological account Enhances cause-and-effect, and decreases anxiety, insecurity and confusion Reduces disparity between what the child is feeling (fear) and current reality (safety: with parents and therapist) Reduces isolation, feeling of being unknowable and different Creates the ability to alter the child’s dysfunctional patterns of interaction Facilitates grief which leads to developmental growth

Explicit or Declarative Memory We have a conscious ability to retrieve the memory and state the facts and events. We can recall the event Implicit or Nondeclarative Memory Implicit memory systems store emotions, sensory experiences, and expectations and assumptions about relationships based on prior experiences Implicit memories form early in life prior to the individual having language They cannot be recalled but they can be triggered Briere , John and Catherine Scott (2006.) Principles of Trauma Therapy: A Guide to Symptoms, Evaluation and Treatment, Thousand Oaks: Sage Publications.

“When salient experience must be unnoticed, disallowed, unacknowledged, or forgotten, the result is incoherence in the self structure. Interconnections among experiences cannot be made, and the resulting gaps in personal history compromise both the complexity and the integrity of the self” Ogawa et al, 1997

Completely truthful disclosures help the child to heal and grow 23

A Tool-Box of Techniques Telling the narrative “story”…
Start at the beginning Cases of Limited information Verbal and concrete methods Pace- maintain emotional regulation Value free – the child decides who to love Use adoption language: birth mom, birth dad, etc. Adjust language according to child’s age: chronological and developmental Repeat, repeat, repeat!

Anticipate questions… Say “I don’t know” as needed “Why did my birth parents use drugs?” “Do you think my birth mom thinks about me?” “Do you think she is in jail?” “Does she have any more children?” “If they get better, can I go live with them again?” “Why didn’t anyone in my country want me?” “Why didn’t the orphanage ladies take me home?” “Do you think my orphanage friends got adopted?” “Are my birth parents alive?” “Are my siblings safe?” “Do you think my siblings think about me?” “Why did you pick me?” “What would you have done if I had been your baby?”

Parental Involvement… Parent(s) always present helping Parent(s) provide comfort Parents learn to speak the truth and not reframe the past Timeline and life book are ongoing projects

The Life Book A BOOK THAT RECORDS A CHILD’S HISTORY FROM THE BIRTH PARENTS TO THE PRESENT

The Timeline Allows child to place emotions in the right place Provides for concepts of past, present and future Helps child understand permanency – “forever”

Music is the Language of the Spirit
A Tool-Box of Techniques Music is the Language of the Spirit

Researchers have hypothesized which came first: music or language Listening to music is an activity even when it’s background noise. Keeping time, postures change to reflect the story, evokes emotion. Brings up memories and feelings associated with that time.

Preverbal Trauma Challenges…
Trauma occurring before the development of language. Narrative memory has not developed fully. Sensory information still filters through the amygdala.

There’s a lot going on in there!!
Asymmetric differences between the left and right hemispheres in adults. This asymmetry is reversed in the fetus and may carry into early childhood. Injury or trauma introduced at this time can lead to an overdevelopment of the right side hemisphere.

Interventions Airplanes What happens if the airplane crashes? Everyone looks for the black box!

Because the Black Box records EVERYTHING! The talking on the radio, the weather, turns, ups and downs…but it can’t tell the difference among people or ‘now’ and ‘back then.’ It doesn’t really think…it just records information and feelings so we can keep ourselves safe.

Everyone has a Black Box in their brain. It’s how we learn. It can’t tell the difference between good and bad, right or wrong, or even moms. It’s main job is to tell us if it is safe or dangerous. Maybe there’s a part in your Black Box that recorded moms are mean and hurt their kids? I think I can help you fix it if you want.

Children’s Books Journaling Art Role-plays Photos Videos

Nurture Repeating the “Cycle of Needs”

A Tool-Box of Techniques Nurture
Eye contact Staring contest Play peek-a-boo Look at each other and name ways you match Candy kiss hunt Face painting “I love you” in soap on mirror Touch Styling hair Scratching back Hand on the shoulder Hold hands while walking Kisses Clapping games Hugs, hugs and more hugs!

Talking Sing together Read together Talk in the car Nursery rhymes Trace a word on your child’s back Identify faces What a beautiful baby!

Smell Lotion Candle Bake cookies Warmth Dry mittens in the dryer Hot chocolate Pup tent Special blanket

Motion Blow bubbles Fly a kite Rock Catch fireflies Make a snow angel Shoot baskets

Food Have a banana split for dinner Go on a picnic Say, “Yes, you may have a cookie after dinner Have a tea party Eat by candlelight with the kids Cut sandwiches into heart shapes Sprinkle chocolate chips on pancakes Nurture with rather than battle over food

A Tool-Box of Techniques - Theraplay
Structure The therapist and parents select and lead the activities. This helps the child develop self-control. Engagement Offers stimulation, variety and a fresh view of life-the child understands that surprises can be fun! Nurture Soothing, quieting, caretaking activities make the world feel safe, predictable and secure Challenge Helps the child take a mild age-appropriate risk. This promotes feelings of competence and confidence. Stresses cooperation

A Tool-Box of Techniques YOGA
Improved flexibility, strength, balance, muscle tone Increases the individual’s awareness of their breathing, and then teaches way to regulate breathing. This is important for calming down. Pizer, Ann. Benefits of Yoga. [online]. Taming the Monkey Mind This is the mind that jumps from thought to thought like a monkey jumps from tree to tree. Emphasis is on being in the present moment. The mind gains the ability to focus and concentrate. Stress relief via stretching. Stress-related tension is stored in the body, making a person feel tight, and often causing pain.

A Tool-Box of Techniques Infant Massage
Helps in relieving discomfort from gas, colic, and constipation Improves blood circulation aids in digestion Improves quality and amount of sleep Enhances development of the nervous system and Stimulates neurological development (brain function and brain development) Reduces aggression (Cozolino) Increases alertness and heightened awareness Reduces stress hormones Improves immune function Stimulates oxytocin, the “nurturing hormone” Deepens bonding: Stimulates growth and healthy development of body, mind and spirit Relaxing and soothing International Association of Infant Massage. What are the Benefits of Infant Massage?

A Tool-Box of Techniques Neurofeedback
“Training for the Brain”

Vineland Adaptive Behavioral Scales
Research Vineland Adaptive Behavioral Scales

The Vineland Measures Development…
Research The Vineland Measures Development… Socialization Domain Interpersonal Relationships Play and Leisure Time Coping Skills Motor Skills Domain Gross Fine Behavior Internalizing Externalizing Communication Domain Receptive Expressive Written Daily Living Skills Domain Personal Domestic Community

Chronological Age 4 years, 4 months 5 years, 7 months
Communication Receptive 1 year, 3 months 1 year, 6 months Expressive 2 years, 6 months years, 5 months Written 4 years, 5 months years, 11 months Daily Living Skills Personal 3 years, 1 month years, 0 months Domestic 4 years, 6 months years, 6 months Community 3 years, 1 month years, 5 months Socialization Interpersonal Relationships 1 year, 1 month years, 0 months Play and Leisure Time 0 years, 4 months years, 8 months Coping Skills 1 year, 10 months years, 4 months Motor Skills Domain Gross 2 years, 1 month years, 11 months Fine 3 years, 6 months years, 7 months Behavior Internalizing Clinically Significant Clinically Significant Externalizing Elevated Elevated

Chronological Age 6 y, 0m 7 y, 0 m 8y, 3m
Communication Receptive 1 y, 6 m y, 11 m y, 2m Expressive y, 2 m y, 0 m y, 6 m Written y, 2 m y, 9 m y, 9 m Daily Living Skills Personal y, 7 m y, 1 m y, 6m Domestic y, 4 m y, 11 m y, 7m Community y, 7 m y, 5 m y, 5m Socialization Interpersonal Relationships y, 3 m y, 3 m y, 5 m Play and Leisure Time y, 9 m y, 10 m y, 10m Coping Skills y, 6 m y, 3 m y, 2m Motor Skills Domain Gross y, 5 m y, 11 m y, 10m Fine y, 6 m y, 6 m y, 10m Behavior Internalizing CS CS CS Externalizing CS CS CS

Communication Receptive 1 year, 11 months years, 11 months Expressive 6 years, 4 months years, 7 months Written 9 years, 0 months years, 8 months Daily Living Skills Personal 6 years, 1 month years, 6 months Domestic 5 years, 5 months years, 6 months Community 7 years, 6 months years, 7 months Socialization Interpersonal Relationships 1 year, 1 month years, 9 months Play and Leisure Time 2 years, 9 months years, 3 months Coping Skills 1 year, 6 months years, 5 months Motor Skills Domain Gross Age Equivalent Age Equivalent Fine 4 years,11 months years, 10 months Behavior Internalizing Clinically Significant Elevated Externalizing Clinically Significant Elevated

Communication Receptive 1 year, 9 months years, 11 months Expressive 5 years, 11 months years, 7 months Written 9 years, 2 months years, 10 months Daily Living Skills Personal 5 years, 11 month years, 3 months Domestic 7 years, 7 months years, 6 months Community 8 years, 11 months years, 6 months Socialization Interpersonal Relationships 0 year, 11 month years, 7 months Play and Leisure Time 3 years, 2 months years, 3 months Coping Skills 2 year, 3 months years, 6 months Motor Skills Domain Gross Age Equivalent Age Equivalent Fine Age Equivalent Age Equivalent Behavior Internalizing Clinically Significant Elevated Externalizing Clinically Significant Elevated

Part III Parents Need Nurture Too!

Parents Need Nurture Too!
Complex Trauma creates a Complex Family System Most adoptive families are healthy prior to the arrival of a child with a history of complex trauma. However, the family often appears unhealthy upon entering services. The state of the family is a response to the challenges involved in parenting a child with complex trauma issues.

Trauma, by definition… A single experience or an enduring or repeating event or events, which completely overwhelm the individual’s ability to cope—consumption and depletion of coping skills. There is frequently a violation of the person’s familiar ideas—expectations—about the world, and the person is put in a state of confusion and insecurity—cognitive dissonance. This is also seen when people or institutions depended on violate or betray the person in some unforeseen way—isolation. It usually involves a feeling of complete helplessness in the face of a real or subjective threat to one’s life or to that of a loved one’s life, integrity and sanity—losses. There is also an inability to integrate the emotions—grief and negative emotional climate—involved with the traumatic experience.

The Dynamics of the Complex Family System
Expectations Cognitive Dissonance The Consumption and Depletion of Coping Skills The Emotional Roller-Coaster Isolation A Sea of Grief

The Dynamics of the Complex Family System Expectations
I want to help a child in need I am unable to have children I heard an ad on the radio Love will be enough I know what they have been through My spouse or partner wants to adopt I thought a child would strengthen our marriage A relative’s child needs my help I want my children to have more siblings I want to adopt a young child I don’t want to deal with birth parents I didn’t expect to adopt (foster parents)

The Dynamics of the Complex Family System Expectations – Additional Layers
I expect … my partner to support me parenting to resolve past issues my faith to remain strong my extended family and friends to be supportive to be supported by professionals to be supported by society at large

Typically-Developing Children “I expect to have a playmate”

The Adoptee “I think you will abuse me.” “I think I am moving somewhere else.” “I think you are another orphanage.” “I am unlovable.”

Expectations and reality collide

The Dynamics of the Complex Family System Cognitive Dissonance
is defined as inconsistencies between expectations and experiences. As humans, we do not like inconsistency. the greater the inconsistency, the more motivation there is to reduce it. (Festinger, 1957)

The Dynamics of the Complex Family System Cognitive Dissonance
Perhaps the greatest source of cognitive dissonance is the invisible quality of mental health issues. “Why can’t anyone see his problems?” “Why are they always blaming us?”

Adjusting Expectations – Achieving Cognitive Consonance In evaluating expectations and experiences, our goal is to draw conclusions. We must decide: which expectations need to change because they have no rational basis which expectations have created losses that need to be grieved which expectations need to change because they cannot be fulfilled which expectations are valid and can be fulfilled

The Consumption and Depletion of Coping Skills “Nothing works!” “We’ve tried it all!”

Ineffective Coping Styles - Parental Punitive Accommodating – “I give in” Making Extraordinary Efforts Emotionally Withdrawn “Yes, but…” Split

Ineffective Coping Styles – Healthy Kids Withdrawn Self-Sacrificing Acting Out Regressed “I’ll Cover for You” Victim

Ineffective Coping Styles – Repeating the Patterns Trauma Reenactment or Compulsive Repetition Children who have experienced trauma alter the dynamics of the adoptive family in a manner that causes a repetition of their abandonment, abuse, neglect, deprivation or life with a drug addict. Their trauma is reenacted, albeit on a smaller scale, within the adoptive home. (van der Kolk, 1989)

The child who is compulsively repeating his traumatic experience needs the presence of strong attachment figures—adoptive parents

and Effective Coping Styles
Alter coping and attachment styles & Provide New Parenting Tools

Parenting Pearls… Control, Control, Control
What you want to control What you need to control What you can control What you should not control What you cannot control

Pick and choose carefully
Avoid control battles Win the ones you take on 72

Developmental Parenting
Parenting Pearls… Developmental Parenting “Developmental interruptions result in delays that leave the individual developmentally immature”

Developmental Delays Cause and Effect Thinking Problem-Solving Skills
Moral Development Social Skills

Ineffective Parenting Tools
Rewards Incentives Removal of Privileges Time Out Grounding Isolation 75 Keck and Kupecky PARENTING THE HURT CHILD

and Effective Coping Skills
Natural and Logical Consequences Paradox Joining In Choices Time In Praise – “Global” vs. “Specific” Prescribing Symptom “Consistent” vs. “Unpredictable”

Ineffective Parenting Tools
Less Talk No: Threats Reminders Warnings Bribes More Action!

Parenting Pearls… Too much talk causes too little listening

Child arrives with unresolved emotions
The Emotional Roller-Coaster The Impact of Stress on the Adoptive Family Child arrives with unresolved emotions Child acts out behaviorally Parents’ own unresolved issues are triggered. Child and parent engage in negative emotional interactions. A Negative Emotional Climate is Created

The Emotional Roller-Coaster Triggers
Triggers are identifiable situations or events that can create emotional upheaval.

The Emotional Roller-Coaster Triggers
Mother’s/Father’s Day Birthdays Holidays The anniversary of the adoption Anniversary of removal from birth family Illness or death of adoptive parent Divorce School-related projects and classes Airplane rides Visits with birth siblings Birth or adoption of a child Kindergarten or first grade Beginning and end of each school year Puberty Questions/comments from strangers

Avoid Approaching Storms Reduce Angry Reactions
Facing Frustrations Avoid Approaching Storms Reduce Angry Reactions

The Emotional Roller-Coaster “Reactions” not “Consequences”
Parenting, healing forming strong attachments, etc. are about reactions, not consequences.

Isolation Support system shrinks Marital tension Time demands Chaos
Behaviors (socially unacceptable) Financial strain Diminished family fun Lack of services Clip art

A Sea of Grief Grief—the emotional response to loss—is perhaps the most significant dynamic to develop within the adoptive family parenting a child with mental health issues. When it comes to the experience of loss, the primary distinction between death and mental illness is that mental illness is not broadly and publicly recognized as a significant loss, when in fact, loss may be the primary trauma for family members during the course of mental illness (Johnson, 1994).

A Sea of Grief Although losses abound, there is one central loss. That is, the loss of the person that their adopted son, daughter, brother or sister could have been. Additionally, in families with persons with serious mental health illness, there is no difference between parents and siblings in their level of grief (Miller, Dworkin, Ward, and Barone, 1990). Grieving is a chronic—persistent and lasting—process.

Positives - Adoptees More likely to complete high school or the equivalent More likely to attend and complete college Less likely to become teen parents Less likely to abuse drugs and alcohol Less likely to have mental health problems Less likely to be arrested and incarcerated More likely to be employed More likely to have adequate incomes More likely to have health insurance

Positives Parents Typically-Developing Children

Attachment and Bonding Center of Ohio
Books by the Attachment and Bonding Center of Ohio

Attachment and Bonding Center of Ohio
Gregory C. Keck, Ph.D. Attachment and Bonding Center of Ohio 12608 State Road Suite 1 Cleveland, OH 44133

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