Re-Attaching the Brain: A Developmental Treatment Approach for Treating Sexual Behavior Problems in Children and Adolescents Kevin Creeden, M.A., LMHC Whitney Academy East Freetown, MA kcreeden@whitneyacademy .org

A Developmental Framework Development happens across a variety of areas: neurological, physical, emotional, social, cognitive, academic, moral, etc. Development proceeds from the existing competencies

Developmental Framework A variety of developmental models can be used in conceptualizing effective treatment Maslow (1968), Bowlby (1973) Strayhorn (1988), Erickson (1963) Common developmental issues

Common issues Sense of belonging: trust, safety, closeness, dependence Differentiating self from other Self-regulation of physical and emotional responses: delaying gratification Developing cognitive skills

Common Developmental Issues Cognitive flexibility/adaptive problem solving Moral development Empathy Creativity

Clinical Assumptions Trauma in early childhood has a neuro-developmental impact The individual’s own trauma experiences and their current behavior are linked through a variety of trauma associations and cues

Without addressing trauma associated symptoms the integration of new learning and new narratives will not effectively occur There is a physiological response to trauma cues that effects processing, cognitions, emotional response, and behavioral response It is impossible to discuss trauma in children without addressing the quality of parental attachment (van derKolk, 2003)

Engaging in abusive behavior is primarily focused on meeting relational needs Safety is the primary goal Competency in relationships and developmental tasks are key protective factors Children do well if they can

Kids Have to Think That You Care Before They Care What You Think

Resiliency Factors Positive attachment to emotionally supportive and competent adults Development of self-regulation and cognitive abilities Positive self-concept Motivation to act effectively

Brain Development and Trauma Brain abnormalities are associated with childhood abuse and neglect (Teicher, 2002; DeBellis, 2001)

Neocortex: Site of higher cognitive functions and sensory integration Hypothalamus: controls appetite, hormones, and sexual behavior Hippocampus: crucial to memory and learning facts Amygdala: responsible for anxiety, fear and emotions Cerebellum: seat of motor control and coordination Brain stem: responsible for sensory input and physiological responses

Brain Structure Function Impairment Amygdala fear conditioning; aggressive behavior; triggers fight/flight Increased arousal, impaired fear conditioning Hippocampus Retrieval of verbal and emotional memory Memory impairment, especially verbal memory Left hemisphere Regulate analytical responses; mediate emotional responses; language processing Difficulties in accurate, effective reading of situation; language processing Corpus Collosum Communication and integration between hemispheres Poor integration and modulation of responses to daily interactions Cerebellar Vermis Production and release of neuro-transmitters Problems regulating physical activity, attention, emotions Prefrontal cortex Center for executive functions Poor organization, rigid problem solving; increased impulsivity

Trauma symptom assessment Assessment Issues Trauma symptom assessment TSCC; TSI Screening for processing difficulties SCAN:A; Bender; RCFT; WCST

Discriminate attachment styles for the parents and child Family of origin issues and expectations of the parents, foster parents, or other caregivers FAM:III; Stress Index for Parents of Adolescents (SIPA); Clinical interview; TSI Discriminate attachment styles for the parents and child Relationship Questionnaire (Bartholomew and Horowitz, 1991)

Behavior specific assessment: sexual knowledge, attitudes, cognitive distortions, focus of fantasies. Personality assessment to examine issues of depression, aggression, anti-social attitudes

Phase Oriented Treatment Stabilization, including education and identification of feelings/somatic states De-conditioning traumatic memories and responses Restructuring traumatic personal schemes van der Kolk, et al , 1996

Maslow’s Hierarchy of Needs

Treatment Interventions Stabilization, deconditioning, and establishing supportive relationships can be re-framed as “containment” WORKING ON TRAUMA thinking, feeling, and talking about trauma Attachment Self-regulation Structure Allen, 2001

Structure Consistency and predictability in the schedule Consistency in expectations Consistency in responses Consistency in environment Use of rituals

Self-Regulation Active learning and practice of a variety of activities and techniques Deep breathing and “counting to 10” Visualization and “safe place” Yoga or tai chi Music, journaling, art Daily exercise Brain gym Biofeedback

Transformations Sensory Stimulation Transformation of information Dispositional representations Enacted behavior Crittenden, 2005

Sensory Areas Proprioception Vestibular Auditory Visual Tactile Olfactory Gustatory

Proprioception Sensations derived primarily from large muscles and joints; especially during movement against resistance Can help person feel grounded DEEP Pressure: often over-rides over arousal

Proprioception examples Weighted blankets or vests Wall push ups Walking Isometric exercise Brain gym Exercise balls Clay work

Vestibular Sensation derived from stimulation of vestibular mechanism in the inner ear Provides a sense of equilibrium and balance Contributes to a sense of one self in space “boundary issues”

Auditory Directly connected to vestibular Sound, music, rhythm serves as a “pacemaker” Different sounds connected to mood, pace Consider different sounds in transition in environments like residential centers and schools

Gustatory Includes oral motor as well as taste Stimulation can help with attention, comfort, and overall organization

Tactile Touch, pressure, vibration, temperature, pain Provides sense of body image, boundaries, self Fundamentally connected to safety, comfort, self-soothing, attachment

General Characteristics Calming Mild Rhythmic Simple Familiar Consistent Soothing Low demand Alerting Strong Fast paced Non-rhythmic Complex Novel Unpredictable High demand

Anxiety and Agitation Deep breathing Isometric exercise Rocking Using weighted blanket Stress balls Calming music Chewing gum Rocking chairs or gliders Yoga Mindfulness Biofeedback Rowing

Grounding Approaches Strong tastes Sour candy or hot candy Chewing gum Ice tapping Hot/cold shower Pacing Tapping Movement: yoga, tai chi

Depression Weighted vest Movement and exercise Beanbag tapping Warm pad Scented lotion Stroking/brushing Calming techniques are often not helpful

Developmental Model Self-Regulation Attachment Cognitive skills Social Skills Adaptive Living Skills Healthy Sexuality

Self-regulation (2) Identifying triggers Connecting sensations w/ thoughts, feelings, behaviors Identifying choices aspects of BrainWise

Attachment styles: Bartholomew Secure Preoccupied Avoidant Dismissive Self Others pos (+) pos (+) neg (-) pos (+) neg (-) neg (-) pos (+) neg (-)

Domains of Impairment: Complex Trauma Cook, Spinnazzola, et al (2005) Attachment Distrust Social isolation Attunement difficulties Boundary problems Problems with perspective taking

Addressing Attunement Eye contact Thoughtful use of touch Mirroring Being “in sync” Listen, reflect, check

Brain Wise: The 10 Wise Ways Wizard Brain over Lizard Brain Constellation of Support Recognize Red Flag Warnings Exit the Emotions Elevator Separate Fact from Opinion

Wise Ways Ask Questions Identify Your Choices Consequences: Now and Later; Affecting Others Set Goals and Form a Plan Communicate Effectively

6. Domain: Healthy Sexuality Elements: Understanding Rules and Limitations of Sexual Behavior at Whitney Interventions: Present and discuss Whitney Sexual Behavior Rules Elements: Self-Regulation (see above) Elements: Maintaining appropriate personal space (see above) Interventions: Kornblum: Chapter 2 Recreational therapy Elements: Accurate Sexual Information Interventions: Sex ed curriculum (medical) Elements: Sexual Behavior in context of relationships Interventions: Sex ed curriculum (clinical) Elements: Cognitive distortions Interventions: BrainWise curriculum: Separate Fact from Opinion Elements: Role models and masculine identity Interventions: Circles curriculum Family therapy Group therapy

Domain: Self-Regulation Elements: Behavior Management Interventions: Level System Individual behavior management plan Elements: Sensory Integration Interventions: Complete Sensory Profile Introduce to Sensory Room Develop individualized sensory/self-regulation tools Elements: Self-regulation skill training Interventions: Daily stress buster exercises Use of biofeedback tools: Wild Divine; pulse meters, etc. Dialectical Behavior therapy exercises: (Linnehan) Elements: Safe Place Interventions: Describe, write about, build, develop safe places both real and imagined (visualization) EMDR: safe place installation (individual) Elements: Adaptive Problem Solving Skills Interventions: BrainWise curriculum