1. Visible Child Initiative Training Series
Attachment Disorder and Symptoms in Adolescents Reducing fear, shifting thinking and promoting belonging for teens with attachment disruption and trauma
Visible Child Initiative Training Series
July 22, 2014
Presenter:
Krista Nelson –LICSW LMFT Wilder Foundation Attachment and Trauma Training Program /

2. between individuals that really matters, the nature of attachments”
“It is the space
between individuals that really matters,
the nature of attachments”
David Brooks- New York Times

3. The Visible Teen in our Programs
Adolescents in Housing Crises
Within every young person is a story of how she has come to be here
Often, a core part of that story involves loss of protective adults and a perceived need to survive on one’s own, ready or not
Each has an attachment story

4. Attachment Is…
Evolution’s way of maximizing survival in a dangerous world- can’t survive alone
Hard wired quest to stay close to other whom you have enduring emotional ties. Stress activates need to seek out/engage/get relief.
A dance of “call and response” creates a neural, life long map for how to manage feelings & be with others
Provides secure base from which to explore and learn about world, across cultures
Base for surviving terror, helplessness- haven for healing, making sense, resilience – trauma prevention

5. John Bowlby- “Attachment is an emotional, survival driven tie to a specific person or persons that endures across space and time.” 1969
44 Thieves- Real life experiences of how caregiver deprivation shapes current behavior.
“The young child’s hunger for his mother’s presence and love is as great as his hunger for food”.
Shifted the mental health paradigm -emotional accessibility and responsiveness builds health- loss, isolation creates harm
“Dependency is an innate part of being human, rather than a childhood trait we outgrow”
Today’s neglected children become tomorrow’s neglectful parents

6. Stress
The emotional and physiological reaction to a threat, whether real or imagined, results in a series of adaptations by our bodies
Stress keeps us out of relationship with one another.
Attachment is about coping through stress

7. Parent Responsiveness- “Synchrony”
Predicts security in infant, self regulation in the two year old and moral orientation and empathy in the teen
Father son tumble play linked to lower aggression in 2-6 year olds
Mother- teen talking linked to depression reduction and increased social savvy

8. How the brain forms… What the mother experiences the baby experiences.
Excitement
Hope
Joy
Dread
Overwhelming stress
Chemical use

9. Neurological Patterning “The Brain is a Pattern Seeking, Meaning Making Machine”
Caregiver remains with infant in face of increasing levels of arousal (too much activity) and helps make arousal tolerable.
Exchange of pleasure, joy generates Oxytocin which modulates cortisol levels. Brain learns to organize this energy.
Sets template for how such interactions feels to infant and are coded in implicit memory.

10. Cycle of Need in Infancy

11. Child B

12. Cue or Miscue Needs?

13. Cycle of “Want” in Toddler Years
Takes in image of self from caregiver’s mind
Learns to make sense of what he experiences through experimenting and checking back (Are you there?)
Integrates “constancy”- You are mean and you are still Mom
NO! I do it!

14. Teen Years
Do best with a “secure base” from which to explore and a “safe base” to call upon when distressed
At times, actively avoid relying on parents when stressed- learning to not get needs met by adult
Sometime seeks parent to “co-regulate” intense emotion
Parent can assist with “life script” – Who am I?

15. Attachment security provides the developing child….
Capacity to reflect on own states and make meaning, not just be the state- This is “Mentalizing” “I am disappointed because…”
See that what I am feeling can be different from what you are feeling and that what I do affects you- Seeds of Empathy
Sets up core beliefs about who am I and who others can be to me- Seeds of Self esteem and Trust
Core lens for interpreting my own or other’s behavior

16. Life Skills Learned in Attachment Relationships
I can calm my body down when I am upset.
I can figure out what to do when I am bored.
I can ask for help if I need it.
I can see how my actions effect another.
I can stand being frustrated as I take on new challenges.
I can hear “No” and shift gears, even when I want to keep doing what I am doing.
I can survive hard times.
I know that I am connected to others and this brings feelings of calm, sometimes joy.

17. Regulation Partnership
When child has someone who helps them manage what is overwhelming, that child can begin to explore her world through trial and error, take risks and form a coherent view of self and the world.
Resilience is the ability to respond adaptively to challenge, strengthened by tie to at least one other

18. Insecure Attachment Patterns Functional way to get needs met from relationship you got
And yet- not fixed
Parents can overcome histories of trauma and poor attachment- change their approach towards own child
Avoidant child
Ambivalent child
Disorganized child
Dismissing teen
Preoccupied teen
Unresolved teen

19. Who Did This For You?- Life Script
Think of five words to describe your parent(s) when you were a kid.
Think of an example that illustrates these five words from your memory.
What adults were you closest to and why?
What would your parents do if you were upset, sick, distressed?
Why did they act the way they did?
Are you close to your parents now?

20. An attachment lens organizes what we see and help us determine where to go……
Consider…
What happened between this teen and his caregivers, especially age 0-3 as his brain was forming?
How does teen move from stressed to calm or frustrated to able to act? Who modeled this for him?
How does teen feel safe? Can he hold this feeling of safety in different settings?
Who is teen socially? Can he form ties? Can he ask for help? Can he help others?
Can this teen step back and reflect on his actions, “think aloud”?

21. Thinking of a Child with Attachment Trauma
“I don’t need anyone. I am alone”
“I need to be exactly what you need, to know I am okay. I don’t exist if you aren’t in sight.”
“People always leave me”
“I am going to die when I feel- can it end?”
“I always mess up- People expect me to be perfect”
“No one is safe. I am not safe.”

22. Tasks of Teen Complicated by Attachment Insecurity/Trauma
Seek sexualized touch for belonging
“All about me” survivor brain
Lying, stealing, tantrums taken to new levels with stiffer consequences
Self sabotage in school and activities
Unresolved grief from past attachment ruptures
Accepting “no” is submission, loss of control
Adults have been both comfort and source of fear
Feel most alive when in negative interaction
Acting out, like shoplifting can actually be a cry for some response- “see me”

23. Teens with early histories of chronic stress and attachment loss
If we can’t reduce our stress internally, we automatically seek to calm stress externally in how we act with others

24. What has been the nature of your teen’s attachments?
What kind of “regulation partnership” has she had with adults with responsibilities to guide and protect her?
Does he move closer or farther from others when in need?
Does he get his needs met from whomever is present, “anyone will do”?
Has she lost trust that people matter?
What kind of “protective skin” do you see?

25. Adverse Childhood Effects www.ACEstudy.org
Link between childhood toxic stress and chronic diseases people develop as adults
The more ACES- see disrupted neurodevelopment, social emotional, cognitive impairments, adoption of health-risk behaviors, early death
Ten types of toxic stress events:
Emotional, sexual, physical abuse
Emotional and physical neglect
Parent addicted to alcohol/drugs
Seeing caregiver abused
Family member in prison
Family member with mental illness
Parent who had disappeared – left or divorced
“Ace” score- 70% of 17,000 in study had at least one

26. Lifetime Consequences
Understanding Relational Trauma’s Impact: “ACEs Too High”

27. Paradigm Shift Traditional View
The client is oppositional, defiant and manipulative.
The behaviors are the client’s way of controlling everyone around them.
New View
The client is in a highly anxious, stressed state of fear.
The behaviors are the client’s attempt to reduce the fear and stress in order to feel calmer.

28. What Labels do the Teens you know already carry with them?
Bad kid
Manipulative
Lazy
Violent
User
Drifter
ADHD
ODD
Conduct Disordered
PTSD
RAD
FASD

29. Mid-range emotion and self regulation
Regulation is balanced flow of energy and information throughout systems of brain
Mid-range emotion
New Learning
Arousal
Krista
Trigger
Balance
Ann Gearity, Making the most out of milieu treatment

30. Ann Gearity, Making the most out of milieu treatment
Hypo arousal- hyper arousal When children experience too much fear and “check out.” Habitual Movement of Brain Stress overrides Cortical brain
Mid-range emotion
Dissociation
New Learning
Arousal
Krista
Trigger
Balance
Ann Gearity, Making the most out of milieu treatment

31. Arousal: It’s Physiological!
Hyperarousal:
Flight/fight response
Optimal arousal: Social engagement response
Window of tolerance
Many children with difficult and severe behaviors live in a perpetual state of distress. “Their high level of distress distorts their perception of the world and keeps them living in a state of fear. With this understanding, it becomes clear that in actuality, their behaviors are perfectly normal –normal considering their internal state of distress.
It is just that it is their normal, not our normal. “ Forbes, p.33
Hyporarousal:
Immobilization response

32. Diagnosis and Insecure Attachment
Contributor to, not causation of mental disorders
Impact of attachment disruption or trauma crosses domains of behavior, mood, development delay, thought and social interaction- no one diagnosis will do
Mind- body mosaic of concerns/targets for treatment
What diagnoses are commonly used today?
Anxiety NOS
Dysthymia
Oppositional Defiant Disorder
Adjustment Disorder to Posttraumatic Stress Disorder
Reactive Attachment Disorder

33. Reactive Attachment Disorder (IDC 10 Code F94.1)
Essential Features:
absent or grossly underdeveloped attachment between child (at least age 9 months ) and caregiving adults
Can form selective attachments, but due to serious social neglect, fail to show behavioral manifestations of selective attachments, such as don’t seek caregiver for comfort or protection.
Diminished or absent expression of positive emotions during interactions with caregivers
Emotion regulation capacity is compromised- Functional impairments across many early childhood developmental domains
Associated with social neglect, yet occurs in > 10% of children in foster care/institutions
Use with caution in children over age 5

34. Disinhibited Social Engagement Disorder (F94-2)
Essential Features:
Pattern of behavior- culturally inappropriate, overly familiar behavior with relative strangers- violates social boundaries
Diminished or absent checking back with adult caregiver after venturing away
Willingness to go with unfamiliar adult with minimal hesitation
History of insufficient care from social neglect or deprivation or repeated change of caregivers or reared in institutions that limit opportunity to form selective attachments
Rarely seen in clinical settings- occurs in 20% of severely neglected children
Older children- see inauthentic expression of emotions & indiscriminate behavior with peers in adolescence

35. Explaining RAD to a teen client
There are 2 types, some avoid being close to people at all and some get close way too fast and then move on quickly to new people, never staying close for too long
Early exposure to abuse, neglect or too much stress on your developing brain shaped the way your brain was set up to take in and process information.
You likely have an enlarged “alarm system” in your brain that says danger whenever you feel strong emotions
It is hard to hold onto problem solving parts of your brain when you feel stressed
You don’t know how to relax into being with another person . It does not feel safe, joyful or calm to be with someone who counts.

36. For kids who had predictable safe caregivers, hearing “no” acts as a break in the brain inside. For you, “no” can bring a feeling of powerlessness and a need to fight, run or disappear.
Part of you is still learning things little kids learn like calming yourself down when frustrated, how to reflect and talk to yourself about what to do next, read cues of others socially and how to enjoy making others feel good
RAD is not permanent- Your brain can take in new ways of thinking and feeling about being in close, lasting relationships in ways that feel good and safe- it just takes a lot of repetition for the brain to know this

37. Engaging the Attachment System for Change

38. The Mindful Adult
Think differently about this child. There is no absolute truth in how to see a situation. Compliance to adult is not the ultimate goal.
Accept piece of truth in each point of view
Be willing to sit with uncomfortable feelings of child and of yourself. Feel teen’s pain.
Cultivate a “Wise Mind”-
Meditation- Present Moment- Breathing

39. Helping Residents with Attachment Trauma Heal in Our Homes
Clients need safe relationships with someone who can do PACE (playful, accepting , curious, empathic) and keep them safe
Clients are supported to Regulate their Bodies and Emotions
Clients can Reflect on and Tolerate own Experiences
Clients can feel Competent
Clients can to make sense of their struggles and see a future for themselves

40. If our clients are chronically acting out or misbehaving, they are attempting to communicate to you that they are unable to handle their overwhelming internal stress themselves without your help.
The repetition of two things can change the brain:
Positive relationships
Positive environment

41. Creating Safety First Staff - Now the Resident
Dance - follow – lead – follow, follow, lead
Connect: read their cues
SPACE : Structuring
Playful
Accepting
Curious
Empathic

42. Attachment’s Purpose- Regulation of Emotion with Felt Security as Goal
Caregivers need to anticipate times when child’s emotions become dysregulated.
Seek to reestablish a moderate level of emotional arousal in child (co-regulation), and then . . .
Rejoin with the youth through reviewing what happened and what skills are needed to manage arousal differently, next time.

43. Attunement Need 15 positives for each time say “no”
Playful, curious exchanges connects left and right hemispheres of brain
“Feel Felt” – How do for a big old teen?
Singing, dancing, laughing, fishing, quilting, lotioning, wrestling, touching, building, catching, sitting, watching…..

44. Relational Regulation - the positive feedback loop:
Adult focuses on staying in relationship with the child.
Reminds self that the child is scared, not angry
Remembers that the fear is about ourselves, NOT the child.
Remembers that 95% of the time, safety is not the real issue. It is our own fear that drives an aggressive situation into a dangerous situation.
Remembers that fear makes everyone become more demanding, rigid, controlling
“It is Ms. B to you” -
Stay with, through many trials

45. Matched Intensity
Feel and show that you get teen’s disappointment with tone of voice and body
Show teen how to come down off of intense emotion
Do the unexpected (from the fight)
Compliment, hug, eat cookies
Be a “sportscaster” Notice moment by moment in concrete language
Reframe- address the core emotional issue

46. How can your housing setting space be co-regulating?
Sensory stuff- touch, smell, see, taste
Comfort cubbies- placed of refuge
Yoga moves
Mindfulness
Music
Movement
Schedule- predictable, visible

47. Practical Ideas Cool down space with sensory items
Staff generate list of youth’s likes and dislikes- know triggers
Pictures in space depict ways youth belongs, participates
Rituals, Routines
Dance /Music/knitting
Safety crew
Structure
Nurture
Engage
Challenge

48. Therapy Interventions Clinic, Home or School Builds a Bridge between Teens and Their Key People
Practice attachment with adult resource people
“internalize a thermostat for regulating stress through attunement”
Self Regulation “tolerating waves of feeling so can act on own behalf”
Mentalizing- “seeing self from outside and others from inside”
Why Am I
Talking?

49. Power of Story Telling Adolescent Journey toward Self
Resilience- inward Communion and external Community
“Nestled Russian Doll”
Coming of Age Ritual
“Suffering Skin”
One minute narratives
Collages- parts of self into whole
Raps- Spoken word

50. Real Life Outcomes
Teen knows she can be both dependent and independent without losing core relationships
Fear and anger are smaller, hope and joy are possible
Teen can accept nurturance, protection and challenge from key adults in his life
Teen knows that she belongs and has worth through connection to at least one other
Teen can make sense of past loss/trauma experiences, through knowing what strategies he used to survive and being aware of how he can do relationships today, in safer times

51. Potential Treatment Goals-Teen
Reducing Fear
Increase capacity to accept adult help and care
Allow adult to help manage strong emotions (regulation)
Learn to accept feedback and redirection from caregiver
Has reliable ways to reduce stress in face of threat
Shifting Thinking
Select key adults for help with problem solving
Practice showing awareness of how peer’s thoughts or feelings can be different from own
Promoting Social Belonging
Increase ability to “play” in reciprocal manner
Able to stick with a social activity through successes and set backs

52. Potential Treatment Goals- Parent (thanks, Carol Siegel)
Read child’s intentions in the moment to help child learn her own mind.
Respond to child’s very slight overtures to help him feel effective.
Verbalize for child what she is feeling or wanting as much as you can tell.
Read child’s nonverbal communication so child learns to connect behavior and emotion/intention
( “You moved away, maybe you need space?”)
Narrate child’s experience and include a solution.
Prepare child for emotional experiences (“We are going to the DMV and you might be bored, what should we bring?”)

53. The capacity to care, share, listen, value and be empathic develops from being cared for, shared with, listened to, valued and nurtured. Dr. Bruce Perry