Presentation on theme: "Attachment-Focused Interventions:"— Presentation transcript:
1Attachment-Focused Interventions: ABC of Ohio presents…Attachment-Focused Interventions:Cultivating Nurturing Environments to Facilitate Parent-Child Attachment
2Developmental Trauma Disorder Part ITheoretical Rationale:Developmental Trauma Disorder(Complex Trauma or Reactive Attachment Disorder)
3DEVELOPMENTAL TRAUMA DISORDER (Cook, Blaustein, Spinazzola and van der Kolk, 2003)DefinitionChildren’s experience of multiple traumatic events that occur within the care giving systemPrenatal exposure to drugs/alcoholNeglect/InstitutionalizationAbuseAbandonment/Multiple MovesPain/Illness/HospitalizationInvolves simultaneous or sequential occurrences of child maltreatment—that are chronic and begin in early childhood
4DEVELOPMENTAL TRAUMA DISORDER (Cook, Blaustein, Spinazzola and van der Kolk, 2003) Areas of ImpairmentAttachmentAffect RegulationDissociationCognitionBiologyBehavioral ControlSelf Concept
5ATTACHMENTAttachment is the process by which an emotional connection develops between an infant and his/her caretakerThis process organizes the infant physiologically and psychologicallyAttachment becomes the basis for how he/she will relate to the world, learn and form relationshipsIn addition to the basic needs such as food, shelter and clothing, the infant needs emotional care which is essential for his/her developmentAttachment grows through daily interactions between caretaker and infantSmiles, nurturing touch, eye contact, mutual play build trust and security in the childThis first relationship becomes the blueprint for all future relationshipsIt is also the origin of conscience development, empathy, self-esteem and cause and effect thinkingInsecure attachment patterns seen in 80% of maltreated children5
7DISSOCIATION AFFECT REGULATION Difficulty with emotional self-regulationDifficulty describing feelings and internal experienceProblems knowing and describing internal statesDifficulty communicating wishes and desiresPredisposed to earlier onset of affective problems, which is associated with more episodes and poorer outcomeDistinct alterations in states of consciousnessTwo or more distinct states of consciousnessHyperarousal & DissociativeBegins as a protective defense mechanism and then is utilized more frequently as trauma continues
8Cognitive Problems with… Irrational cognitions Sustained curiosity/initiativeProcessing new informationFocusing and completing new tasks (hypervigilence vs. hyperactivity)Understanding own contribution to what happens to them (cause-and-effect thinking)Object constancyOrientation with time and spaceLearning disabilitiesAbstract thinking
9Biology Experiences impact brain development Problems with…Experiences impact brain developmentLifelong reactivity to stressProblems with coordination, balance, body toneSomatizationAnalgesia (inability to feel pain)Hypersensitivity to physical touchWide variety of medical problems: pelvic pain, asthma, skin problems, autoimmune disordersSensory Integration Dysfunction
10Behavioral Control Poor impulse control Self destructive behavior AggressionSelf soothing behaviorsSleep and eating disturbancesSubstance abuseExcessive complianceor oppositional behaviorReenactment of traumatic past
11Self Concept Lack of coherent sense of self Disturbance of body image Low self-esteemPoor sense of separateness
127 Core Issues The Adoption Overlay LossGriefSelf-conceptIdentityShame and GuiltIntimacy and RelationshipsControl
13Translating Theory into Practice: Part IITranslating Theory into Practice:A Tool-Box ofTechniques
14Develop a Coherent Narrative Treatment PrinciplesParent-Centered andChild-FocusedDevelop a Coherent Narrative
19A Tool-Box of Techniques TimelineLife BookChildren’s BooksJournalingArtRole-playsVideosMusicTheraplay™YogaMassage
20A Tool-Box of Techniques The narrative is an emotionally rich story that makes sense of one’s life.Affirms realityCreates meaning, provides closure, reduces need to ruminateOrganizes memories—implicit and explicit— into one chronological accountEnhances cause-and-effect, and decreases anxiety, insecurity and confusionReduces disparity between what the child is feeling (fear) and current reality (safety: with parents and therapist)Reduces isolation, feeling of being unknowable and differentCreates the ability to alter the child’s dysfunctional patterns of interactionFacilitates grief which leads to developmental growth
21A Tool-Box of Techniques Explicit or Declarative MemoryWe have a conscious ability to retrieve the memory and state the facts and events.We can recall the eventImplicit or Nondeclarative MemoryImplicit memory systems store emotions, sensory experiences, and expectations and assumptions about relationships based on prior experiencesImplicit memories form early in life prior to the individual having languageThey cannot be recalled but they can be triggeredBriere , John and Catherine Scott (2006.) Principles of Trauma Therapy: A Guide to Symptoms, Evaluation and Treatment, Thousand Oaks: Sage Publications.
22A Tool-Box of Techniques “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
23A Tool-Box of Techniques Completely truthfuldisclosures help thechild to heal and grow23
24A Tool-Box of Techniques Telling the narrative “story”… Start at the beginningCases of Limited informationVerbal and concrete methodsPace- maintain emotional regulationValue free – the child decides who to loveUse adoption language: birth mom, birth dad, etc.Adjust language according to child’s age: chronological and developmentalRepeat, repeat, repeat!
25A Tool-Box of Techniques Telling the narrative “story”… 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?”
26A Tool-Box of Techniques Telling the narrative “story”… Parental Involvement…Parent(s) always present helpingParent(s) provide comfortParents learn to speak the truth and not reframe the pastTimeline and life book are ongoing projects
27A Tool-Box of Techniques The Life BookA BOOK THAT RECORDS A CHILD’S HISTORY FROM THE BIRTH PARENTS TO THE PRESENT
28A Tool-Box of Techniques The TimelineAllows child to place emotions in the right placeProvides for concepts of past, present and futureHelps child understand permanency – “forever”
29Music is the Language of the Spirit A Tool-Box of TechniquesMusic is the Language of the Spirit
30A Tool-Box of Techniques Researchers have hypothesized which came first: music or languageListening 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.
31Preverbal Trauma Challenges… Trauma occurring before the development of language.Narrative memory has not developed fully.Sensory information still filters through the amygdala.
32There’s a lot going on in there!! Asymmetric differences between the left andright hemispheres in adults.This asymmetry is reversed in thefetus and may carry into earlychildhood.Injury or trauma introduced at this time can lead to an overdevelopment of the right side hemisphere.
33A Tool-Box of Techniques InterventionsAirplanesWhat happens if the airplane crashes? Everyone looks for the black box!
34A Tool-Box of Techniques 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.
35A Tool-Box of Techniques 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 ifyou want.
36A Tool-Box of Techniques Children’s BooksJournalingArtRole-playsPhotosVideos
37A Tool-Box of Techniques NurtureRepeating the “Cycle of Needs”
38A Tool-Box of Techniques Nurture Eye contactStaring contestPlay peek-a-booLook at each other and name ways you matchCandy kiss huntFace painting“I love you” in soap on mirrorTouchStyling hairScratching backHand on the shoulderHold hands while walkingKissesClapping gamesHugs, hugs and more hugs!
39A Tool-Box of Techniques Nurture TalkingSing togetherRead togetherTalk in the carNursery rhymesTrace a word on your child’s backIdentify facesWhat abeautiful baby!
40A Tool-Box of Techniques Nurture SmellLotionCandleBake cookiesWarmthDry mittens in the dryerHot chocolatePup tentSpecial blanket
41A Tool-Box of Techniques Nurture MotionBlow bubblesFly a kiteRockCatch firefliesMake a snow angelShoot baskets
42A Tool-Box of Techniques Nurture FoodHave a banana split for dinnerGo on a picnicSay, “Yes, you may have a cookie after dinnerHave a tea partyEat by candlelight with the kidsCut sandwiches into heart shapesSprinkle chocolate chips on pancakesNurture with rather than battle over food
43A Tool-Box of Techniques - Theraplay StructureThe therapist and parents select and lead the activities. This helps the child develop self-control.EngagementOffers stimulation, variety and a fresh view of life-the child understands that surprises can be fun!NurtureSoothing, quieting, caretaking activities make the world feel safe, predictable and secureChallengeHelps the child take a mild age-appropriate risk. This promotes feelings of competence and confidence. Stresses cooperation
44A Tool-Box of Techniques YOGA Improved flexibility, strength, balance, muscle toneIncreases 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 MindThis 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.
45A Tool-Box of Techniques Infant Massage Helps in relieving discomfort from gas, colic, and constipationImproves blood circulationaids in digestionImproves quality and amount of sleepEnhances development of the nervous system and Stimulates neurological development (brain function and brain development)Reduces aggression (Cozolino)Increases alertness and heightened awarenessReduces stress hormonesImproves immune functionStimulates oxytocin, the “nurturing hormone”Deepens bonding:Stimulates growth and healthy development of body, mind and spiritRelaxing and soothingInternational Association of Infant Massage. What are the Benefits of Infant Massage?
46A Tool-Box of Techniques Neurofeedback “Training for the Brain”
48The Vineland Measures Development… ResearchThe Vineland Measures Development…Socialization DomainInterpersonal RelationshipsPlay and Leisure TimeCoping SkillsMotor Skills DomainGrossFineBehaviorInternalizingExternalizingCommunication DomainReceptiveExpressiveWrittenDaily Living Skills DomainPersonalDomesticCommunity
49Chronological Age 4 years, 4 months 5 years, 7 months CommunicationReceptive 1 year, 3 months 1 year, 6 monthsExpressive 2 years, 6 months years, 5 monthsWritten 4 years, 5 months years, 11 monthsDaily Living SkillsPersonal 3 years, 1 month years, 0 monthsDomestic 4 years, 6 months years, 6 monthsCommunity 3 years, 1 month years, 5 monthsSocializationInterpersonal Relationships 1 year, 1 month years, 0 monthsPlay and Leisure Time 0 years, 4 months years, 8 monthsCoping Skills 1 year, 10 months years, 4 monthsMotor Skills DomainGross 2 years, 1 month years, 11 monthsFine 3 years, 6 months years, 7 monthsBehaviorInternalizing Clinically Significant Clinically SignificantExternalizing Elevated Elevated
50Chronological Age 6 y, 0m 7 y, 0 m 8y, 3m CommunicationReceptive 1 y, 6 m y, 11 m y, 2mExpressive y, 2 m y, 0 m y, 6 mWritten y, 2 m y, 9 m y, 9 mDaily Living SkillsPersonal y, 7 m y, 1 m y, 6mDomestic y, 4 m y, 11 m y, 7mCommunity y, 7 m y, 5 m y, 5mSocializationInterpersonal Relationships y, 3 m y, 3 m y, 5 mPlay and Leisure Time y, 9 m y, 10 m y, 10mCoping Skills y, 6 m y, 3 m y, 2mMotor Skills DomainGross y, 5 m y, 11 m y, 10mFine y, 6 m y, 6 m y, 10mBehaviorInternalizing CS CS CSExternalizing CS CS CS
51Chronological Age 7 years, 11 months 9 years, 1 months CommunicationReceptive 1 year, 11 months years, 11 monthsExpressive 6 years, 4 months years, 7 monthsWritten 9 years, 0 months years, 8 monthsDaily Living SkillsPersonal 6 years, 1 month years, 6 monthsDomestic 5 years, 5 months years, 6 monthsCommunity 7 years, 6 months years, 7 monthsSocializationInterpersonal Relationships 1 year, 1 month years, 9 monthsPlay and Leisure Time 2 years, 9 months years, 3 monthsCoping Skills 1 year, 6 months years, 5 monthsMotor Skills DomainGross Age Equivalent Age EquivalentFine 4 years,11 months years, 10 monthsBehaviorInternalizing Clinically Significant ElevatedExternalizing Clinically Significant Elevated
52Chronological Age 11 years, 1 months 12 years, 5 months CommunicationReceptive 1 year, 9 months years, 11 monthsExpressive 5 years, 11 months years, 7 monthsWritten 9 years, 2 months years, 10 monthsDaily Living SkillsPersonal 5 years, 11 month years, 3 monthsDomestic 7 years, 7 months years, 6 monthsCommunity 8 years, 11 months years, 6 monthsSocializationInterpersonal Relationships 0 year, 11 month years, 7 monthsPlay and Leisure Time 3 years, 2 months years, 3 monthsCoping Skills 2 year, 3 months years, 6 monthsMotor Skills DomainGross Age Equivalent Age EquivalentFine Age Equivalent Age EquivalentBehaviorInternalizing Clinically Significant ElevatedExternalizing Clinically Significant Elevated
54Parents Need Nurture Too! Complex Trauma creates a ComplexFamily SystemMost 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.
55Trauma, 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.
56The Dynamics of the Complex Family System ExpectationsCognitive DissonanceThe Consumption and Depletion of Coping SkillsThe Emotional Roller-CoasterIsolationA Sea of Grief
57The Dynamics of the Complex Family System Expectations I want to help a child in needI am unable to have childrenI heard an ad on the radioLove will be enoughI know what they have been throughMy spouse or partner wants to adoptI thought a child would strengthen our marriageA relative’s child needs my helpI want my children to have more siblingsI want to adopt a young childI don’t want to deal with birth parentsI didn’t expect to adopt (foster parents)
58The Dynamics of the Complex Family System Expectations – Additional Layers I expect …my partner to support meparenting to resolve past issuesmy faith to remain strongmy extended family and friends to be supportiveto be supported by professionalsto be supported by society at large
59The Dynamics of the Complex Family System Expectations Typically-Developing Children “I expect to have a playmate”
60The Dynamics of the Complex Family System Expectations The Adoptee“I think you will abuse me.”“I think I am moving somewhere else.”“I think you are another orphanage.”“I am unlovable.”
61The Dynamics of the Complex Family System Expectations Expectations and reality collide
62The 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)
63The 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?”
64The Dynamics of the Complex Family System Adjusting Expectations – Achieving Cognitive ConsonanceIn evaluating expectations and experiences, our goal is to draw conclusions. We must decide:which expectations need to change because they have no rational basiswhich expectations have created losses that need to be grievedwhich expectations need to change because they cannot be fulfilledwhich expectations are valid and can be fulfilled
65The Dynamics of the Complex Family System The Consumption and Depletion of Coping Skills“Nothing works!” “We’ve tried it all!”
66The Dynamics of the Complex Family System Ineffective Coping Styles - ParentalPunitiveAccommodating – “I give in”Making Extraordinary EffortsEmotionally Withdrawn“Yes, but…”Split
67The Dynamics of the Complex Family System Ineffective Coping Styles – Healthy KidsWithdrawnSelf-SacrificingActing OutRegressed“I’ll Cover for You”Victim
68The Dynamics of the Complex Family System Ineffective Coping Styles – Repeating the PatternsTrauma Reenactment or Compulsive RepetitionChildren 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)
69The Dynamics of the Complex Family System The child who is compulsively repeating his traumatic experience needs the presence of strong attachment figures—adoptive parents
70and Effective Coping Styles Alter coping and attachment styles & Provide New Parenting Tools
71Parenting Pearls… Control, Control, Control What you want to controlWhat you need to controlWhat you can controlWhat you should not controlWhat you cannot control
72Pick and choose carefully Avoid control battlesWin the ones you take on72
73Developmental Parenting Parenting Pearls…Developmental Parenting“Developmental interruptions result in delays that leave the individual developmentally immature”
74Developmental Delays Cause and Effect Thinking Problem-Solving Skills Moral DevelopmentSocial Skills
75Ineffective Parenting Tools RewardsIncentivesRemoval of PrivilegesTime OutGroundingIsolation75Keck and Kupecky PARENTING THE HURT CHILD
76and Effective Coping Skills Natural and Logical ConsequencesParadoxJoining InChoicesTime InPraise – “Global” vs. “Specific”Prescribing Symptom“Consistent” vs. “Unpredictable”
77Ineffective Parenting Tools Less TalkNo:ThreatsRemindersWarningsBribesMore Action!
78Parenting Pearls…Too much talk causes too little listening
79Child arrives with unresolved emotions The Emotional Roller-Coaster The Impact of Stress on the Adoptive FamilyChild arrives with unresolved emotionsChild acts out behaviorallyParents’ own unresolved issues are triggered.Child and parent engage in negative emotional interactions. A Negative Emotional Climate is Created
80The Emotional Roller-Coaster Triggers Triggers are identifiable situations or events that can create emotional upheaval.
81The Emotional Roller-Coaster Triggers Mother’s/Father’s DayBirthdaysHolidaysThe anniversary of the adoptionAnniversary of removal from birth familyIllness or death of adoptive parentDivorceSchool-related projects and classesAirplane ridesVisits with birth siblingsBirth or adoption of a childKindergarten or first gradeBeginning and end of each school yearPubertyQuestions/comments from strangers
83The Emotional Roller-Coaster “Reactions” not “Consequences” Parenting, healing forming strong attachments, etc. are about reactions, not consequences.
84Isolation Support system shrinks Marital tension Time demands Chaos Behaviors (socially unacceptable)Financial strainDiminished family funLack of servicesClip art
85A Sea of GriefGrief—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).
86A Sea of GriefAlthough 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.
87Positives - AdopteesMore likely to complete high school or the equivalentMore likely to attend and complete collegeLess likely to become teen parentsLess likely to abuse drugs and alcoholLess likely to have mental health problemsLess likely to be arrested and incarceratedMore likely to be employedMore likely to have adequate incomesMore likely to have health insurance