HANDOUTS Understanding and Treating Complex Trauma in Children & Adolescents The Attachment, Self-Regulation, & Competency (ARC) Approach
presented by Kristine Kinniburgh, LICSW AGENDA Thursday Friday 9:00 Overview on Trauma 8:30 ARC Treatment Framework: • The cost of trauma on society Attachment • The PTSD diagnosis and it’s relevance • How to help children/adolescents who 10:20 Break have been trained to fear relationships feel safe 10:35 Complex Developmental Trauma • • Attachment as the foundation for How to really listen to the messages competency and resilience children/adolescents send • Developmental impact of complex trauma 9:50 Break 12:00 p.m. Lunch 10:05 ARC Treatment Framework: Self Regulation 1:15 Trauma Diagnosis • Teaching children/adolescents: • Α new lens: Developmental Trauma * to know what they feel Disorder * to feel what they feel • Assessment of Complex Trauma * to say what they feel 2:35 Break 11:30 Lunch 2:50 Complex Trauma Treatment 12:45 p.m. Case Application • Core components of complex trauma • Identifying primary treatment targets intervention when working with complex cases 4:15 Adjournment • Putting knowledge into practice 2:05 Break 2:20 Vicarious Trauma and Self Care
• Re-enactment Cycle
• Stepping out of the Cycle: self care strategies 3:45 Adjournment
Sponsored by Kristine M. Kinniburgh, LICSW J&K Seminars, LLC Trauma Treatment Center 1861 Wickersham Lane 1269 Beacon St Lancaster, PA 17603-2327 Brookline MA 02446 (800) 801-5415 Lincoln, MA 01773 [email protected] 857-939-8030 www.jkseminars.com [email protected]
10/30/2012
Annual Cost of Child Abuse and Neglect
Indirect Costs Estimated Annual Cost Understanding and Treating Complex (in 2007 dollars) Special Education $2,410,306,242 Rationale: 1,553,800 children experienced some form of maltreatment in 199311. 22% of maltreated children have Trauma in Children and Adolescents: learning disorders requiring special education66. The additional expenditure attributable to special education services for students with disabilities was $5,918 per pupil in 200077. Calculation: 1,553,800 x 0.22 x $5,918 = $2,022,985,448 Juvenile Delinquency $7,174,814,134 The Attachment, Self Regulation & Rationale: 1,553,800 children experienced some form of maltreatment in 199311. 27% of children who are abused or neglected become delinquents, compared to 17% of children in the general population88, for a difference of 10%. The annual cost of caring for a juvenile offender in a residential facility was $30,450 in 198999. Calculation: 1,553,800 x Competency (ARC) Approach. 0.10 x $30,450 = $4,731,321,000 Mental Health and Health Care $67, 863, 457 Rationale: 1,553,800 children experienced some form of maltreatment in 199311. 30% of maltreated children suffer chronic health problems66. Increased mental health and health care costs for women with a history of childhood abuse and neglect, compared to women without childhood maltreatment histories, were estimated to be $8,175,816 for a Presentation by: population of 163,844 women, of whom 42.8% experienced childhood abuse and neglect1010. This is equivalent to $117 [$8,175,816 / (163,844 x 0 .428)] additional health care costs associated with child maltreatment per woman per year. Assume that the additional health care costs attributable to childhood maltreatment are similar for men who Kristine M. Kinniburgh experienced maltreatment as a child. Calculation: 1,553,800 x 0.30 x $117 = $54,346,699 Adult Criminal Justice System $27,979,811,982 Rationale: The direct expenditure for operating the nation’s criminal justice system (including police protection, judicial and legal services, and corrections) was $204,136,015,000 in 20051111. According to the National Institute of Justice, 13% of all violence can be linked to earlier child maltreatment44. Calculations: $204,136,015,000 x 0.13 = ARC Developed By: $26,537,681,950 Lost Productivity to Society $33,019,919,544 Margaret E. Blaustein, Ph.D. Rationale: The median annual earning for a fullfull--timetime worker was $33,634 in 20061212. Assume that only children who suffer serious injuries due to maltreatment (565,00011) experience losses in potential lifetime earnings and that such Kristine M. Kinniburgh, LICSW impairments are limited to 5% of the child’s total potential earnings22. The average length of participation in the labor force is 39.1 years for men and 29.3 years for women1313; the overall average 34 years is used. Calculation: $33,634 x The Trauma Center at JRI 565,000 x 0.05 x 34 = $32,305,457,000 Total Indirect Costs $70,652,715,359
Wang, CT, & Holton, J. (2007). Total estimated cost of child abuse and neglect in the United States. Economic Impact Study, 1‐5.
Administer ACES Questionnaire
FelittiFelitti Why is trauma informed care so important?important?
Annual Cost of Child Abuse and Neglect Adverse Childhood Experiences Are Very Common
Direct Costs Estimated Annual Cost Percent reporting types of ACEs: (in 2007 dollars) Hospitalization $6,625,959,263 Household exposures: Rationale: 565,000 maltreated children suffered serious injuries in 199311. Assume that 50% of seriously injured victims require hospitalization22. The average cost of treating one hospitalized victim of abuse and neglect was $19,266 in 199933.Calculation: 565,000 x 0.50 x $19,266 = $5,442,645,000 Mental Health Care System $1,080,706,049 Alcohol abuse 23.5% R ationale: Rationale: 25% to 50% of child maltreatment victims need some form of mental health treatment44. For a conservative estimate, 25% is used. Mental health care cost per victim by type of maltreatment is: physical abuse ($2,700); sexual Mental illness 18.8% abuse ($5,800); emotional abuse ($2,700) and educational neglect ($910)44. Cross referenced against NISNIS--33 statistics on number o f eac h inc iden t occurr ing in 199311. ClCalcu ltilations: PhiPhysica lAbl Abuse –– 381, 700 x 0. 25 x $2, 700 = $257,647,500; Sexual Abuse – 217,700 x 0.25 x $5,800 = $315,665,000; Emotional Abuse – 204,500 x 0.25 x $2,700 Battered mother 12. 5% = $138,037,500; and Educational Neglect ––397,300397,300 x 0.25 x $910 = $90,385,750; Total = $801,735,750. Child Welfare Services System $25,361,329,051 Drug abuse 4.9% Rationale: The Urban Institute conducted a study estimating the child welfare expenditures associated with child abuse and neglect by state and local public child welfare agencies to be $23.3 billion in 200455.. Criminal behavior 3.4% Law Enforcement $33,307,770 Rationale: The National Institute of Justice estimated the following costs of police services for each of the following interventions: physical abuse ($20); sexual abuse ($56); emotional abuse ($20) and educational neglect ($2)44. Cross Childhood Abuse: referenced against NISNIS--33 statistics on number of each incident occurring in 199311. Calculations: Physical Abuse – 381,700 x $20 = $7,634,000; Sexual Abuse – 217,700 x $56 = $12,191,200; Emotional Abuse ––204,500204,500 x $20 = $4,090,000; and Educational Neglect – 397,300 x $2 = $794,600; Total = $24,709,800 Psychological 11.0% Total Direct Costs $33,101,302,133 Physical 30.1%
Wang, CT, & Holton, J. (2007). Total estimated cost of child abuse and neglect in the United States. Economic Impact Study, 1‐5. Sexual 19.9%
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Adverse Childhood Experiences ACES Study and Outcome
Increased presence of childhood adverse experience leads to increased risk of:
Depression
Drug addiction
Alcohol use/abuse
Adult sexual assau lt
Adult domestic violence (perpetrator and victim)
Early onset sexuality and sexual promiscuity
Teen pregnancy and paternity
SuicidalitySuicidality
ObesityObesity
Cigarette use
General health problems
ACE Study (Felitti et al., 1998) Curriculum - Blaustein
ACES Study
Estimates of the Population Attributable Risk* (PAR) of ACEs for Selected Outcomes in Women Mental Health: PAR Current depression 54% Depressed affect 41% Suicide attempt 58% Drug Abuse: Why Talk about Trauma? Alcoholism 65% Drug abuse 50% IV drug abuse 78% Promiscuity 48% Crime Victim: Sexual assault 62% Domestic violence 52%
*Based upon the prevalence of one or more ACEs (62%) and the adjusted odds ratio >1 ACE.
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“Gunman Kills 12 in Colorado”
What is “trauma” and how do we define it?defineit?it?
Event Driven Definitions of Trauma: “High school students mourn teen The PTSD Diagnosis killed in crash” Must experience a Traumatic Event, which involves risk of serious injury to self or other and produces intense fear , helplessness, or horror.
“ A common phenomenon” Symptoms of PTSD
25% of young people experience a ReRe--experiencingexperiencing the trauma: traumatic event such as physical abuse, Flashbacks, nightmares, “re“re--living,”living,” or emotional/physical triggering sexual abuse, witnessing violence, war Traumatic Memory is different! and terrorism, natural disasters, illness or injury by the time that they are 16 years Less Narrative, more fragmented into sensory detailsdetails old.old. The Body Remembers
Traumatic Memories are more vivid, like they happened just yesterday.
CoplelandCopleland--LinderLinder N. (2008)
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Rates of Diagnosed PTSD in Children Symptoms of PTSD (NCTSN Dataset) percen Diagnosis t Category Avoidance of trauma reminders and Post traumatic stress disorder 29.7 Other Acute stress disorder 11.9 Trauma NumbingNumbing Traumatic/complicated grief 7.1 51.2 Disorders Acute stress disorder 1.9 Avoiding trauma reminders Dissociation 0.6 General behavior problems 10.5 Attention deficit hyperactivity Forgetting important aspect of the trauma Behavior disorder 5.6 21.5 Problems Lowered interest in significant activities Oppositional defiant disorder 4.6 Conduct disorder 0.8 Depressio 11.0 Feeling detached or estranged from others n Depression 11.0 Generalized anxiety 7.2 Restricted range of affect Separation disorder 1.1 Anxiety Panic disorder 0.1 8.6 Disorders Sense of foreshortened future Obsessive compulsive disorder 0.1 Phobic disorder 0.1 Substance abuse 3.3 Attachment problems 2.6 Sexual behavior problems 1.3 Other Sleep disorder 0.2 7.8 Somatization 0.2 Suicidality 0.2
Prevalence of Psychiatric Disorders Symptoms of PTSD in Abused Children (Ackerman et al., 1998) Hyperarousal Generalized Anxiety Disorder……….59% Difficulty falling or staying asleep Oppositional Defiant Disorder……….36% Irritability or angry outbursts Simple Phobia …………………………36% Difficulty concentrating Posttraumatic Stress Disorder……….34% HyperHyper--vigilancevigilance ADHD…………………………………..29% Exaggerated startle response Conduct Disorder……………………..21% Dysthymia……………………………..19%
Curriculum - Blaustein
Comorbidity in PTSD
88.3%88.3% of men with PTSD met lifetime Does PTSD capture the “face” criteria for 1 or more other Axis I disorders
of trauma?trauma?of 79%79% of women with PTSD met criteria for 1+1+
80%80% of individuals with PTSD meet criteria for another psychiatric disorder (Solomon and Davidson, 1997)
Curriculum - Blaustein Curriculum - Blaustein
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Trauma is Complex: Diagnostic Issues Dimensions of Traumatic Experience PTSD is the single diagnosis currently in Type of exposure the DSM-DSM-IVIV to capture chronic adaptations Age/developmental stage during exposure to traumato trauma Origin of exposure Public versus private PTSD as it stands now was developpped for ChronicityChronicity adults and therefore does not consider Lasting impact developmental variations in symptom Social support manifestation. ( Carrion and Kletter Contextual issues (culture, family, community) (2012))(2012)) Presence/absence of additional resources Presence/absence of additional vulnerabilities PTSD does not capture the impact of Type Individual differences (cultural factors, coping style, II or Complex Trauma exposure. cognitive, temperament) Curriculum - Blaustein Curriculum - Blaustein
DSMDSM--IV Field Trial for PTSD Complex Trauma in the van der Kolk, Pelcovitz, Roth & Mandel, 1994 National Child Traumatic Stress 100
90 NetworkNetwork
80
70 Complex PTSD or DESNOS Bessel van der Kolk, M.D., Joseph Spinazzola, 60 ORSEMENT
D 50 Ph. D., Julian Ford, Ph. D., Margaret Blaustein ,
40 Ph.D., Melissa Brymer, Psy.D., Laura Gardner,
30 BsPH, Susan Silva, Ph.D., Stephanie Smith, Ph.D.
20 PTSD only PERCENT EN PERCENT 10
0 0-4 5-8 9-13 14-19 20-25 >26 N=75 N=92 N=56 N=62 N=16 N=27
AGE AT ONSET OF TRAUMA (years)
2003 Survey of 2,200 children across Gender NCTSN.NCTSN. • Female 56.9% • Male 43.1%
Family Status The Trouble with Thinking Intact Biological 21.3% 1.00% 8.90% Diagnostically Divorce/Stepparents(s) 12.5%
Divorce/Single Parent 31.4% 21.30% Adoptive Home 4.5% 18.20%
12.50% Foster Home 18.2%
4.50% Relative(s) 8.9% 31.40% Family Status Unknown 1.0% Curriculum - Blaustein
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Child Trauma Exposure: Age of OnsetOnset CHILD & ADOLESCENT TRAUMA EXPOSURE Mean Age of Onset: 5.0 (SD = 2.8) • Median: 5.0 TYPESTYPES •• Min, Max: 0, 13.0
Early Exposure: Over 1/3 of the sample is adolescent and yet 98% of clinicians surveyed report average age of onset under 11
Child Trauma History: Number of Child Trauma Most Frequent Exposure Types Exposure Types
60% 59.3% Mean Number of Exposure Types: 2.9 55.6% (SD = 1.8)1.8)(SD 47.1% 45.8% • Median: 3.0 45% 40.8% •• Min, Max: 1, 11 33. 8%
30% 28.1%
History of Multiple Exposure Types: 18.4% 94% of clinicians surveyed report 15% average child exposure to more than
one type of trauma 0%
A ver A A DV S lect P oss gi g CE L C e C N d Care e ir rrorsm (U.S.) a Te
Child Trauma History: Child Trauma Exposure Less Frequent Exposure Types
Duration 15%
Duration of Trauma • Multiple- Multiple-eventevent or chronic trauma: 77.6%77.6% 62%6.2% • Singe Event or Acute Trauma: 19.2% 57%5.7% 3.0% 2.8% • Unknown: 3.2% 1.6%
0% t ical ident d cc saster s/Me Di rorism (Intl.) isplacemen Injury/A Illnes D ed c War/Ter or F
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Relationship of Victims to Perpetrators in Substantiated Cases
90% 81.0% “The girl in the window” 80% 70% 60% 50% Substantiated Cases Substantiated 40% 30%
20% 10.6% Percentage of 5.0% 1.1% 3.4% 10% 0.5% 0.4% 0% Parents Unknow n Pr ov ider s Facility Staff Other Relative Noncaregivers Child Day Car e Foster Parents
Source: CWLA, 1997
Prevalence of Abuse and Neglect
In 2010 there were more than 700,000 Complex Developmental Trauma substantiated cases of abuse and neglect in the United States. There were more than 2 million unsubstantiated cases.
Child Maltreatment 2010
Understanding Trauma in Using Developmental Trauma ChildhoodChildhood Lens:Lens: Traumatic experiences are those that What has this little girl learned about a re are overwhelming, invoke intense relationships? negative affect, and involve some What has this little gggirl learned about dflftld/degree of loss of control and/or herselfherself vulnerability. How did she learn to survive?
Blaustein 2010
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What helps the child survive?
Assumption of danger Think Developmentally: Rapid mobilization in the face of perceived Trauma, lik e a ll exper ience, s hapes threatthreat
the course of development. SelfSelf--protectiveprotective stance
Development of alternative strategies to meet developmental needs
Curriculum - Blaustein Curriculum - Blaustein
Trauma’s Dual Influence on Development Prioritization of those domains of skill / competency / adaptation which help the The Consequence: child child survive their environment and meet Impact on Developmental physical, emotional , and relational needs Competency
DeDe--emphasisemphasis of domains of development which are less immediately relevant to survivalsurvival
Curriculum - Blaustein
The Developing Brain: Systems Impacted By Trauma
PlasticityPlasticity: The brain’s ability to adapt to Regulation of affect and impulses experienceexperience Behavioral control Attention or consciousness UUUsese--ddtdldependent developmen t: SifiSifiSpecific SelfSelf--perceptionperception changes in the brain in response to Attachment/Interpersonal relationships repeated input (patterns) over time BiologyBiology Cognition The brain develops efficient ways to cope Systems of meaning with and respond to daily experience!!! Spinazzola 2010; CTTN Curriculum - Blaustein conferenceconference
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Attachment/Interpersonal Alterations in Attention or Relationships Consciousness
Inability to trust others Revictimization – Involving themselves in Dissociation Derealization Interpersonal similarly dysfunctional Appear to space out May feel like they are in difficultiesdifficulties interpersonal -- -- interactions -- May be forgetful a dream or not in realityyy SililtiSocial isolation Victimizing others - May have no memories Problems with – Replicate their own of certain times Depersonalization boundaries traumas toward others - May have distinct states May not know what it feels like to be in their bodiesbodies
Spinazzola 2010; CTTN Spinazzola 2010; CTTN conferenceconference conferenceconference
Affect Dysregulation SelfSelf--PerceptionPerception
Difficulty with Difficulty Develop a negative Guilt, shame and emotional self-self- communicating view of themselves responsibility regulationregulation wishes and needs Helpless & ineffectual Feel they are to be Difficulty labeling and Self destructive DamagedDamaged blamed for what has expressing feelings behaviorbehavior hdtthhappened to them Undesirable to others Overreact to minor Suicidal DefensiveDefensive Negative body image stress/hyperarousal preoccupation Low self-self-esteemesteem Nobody can Difficulty calming Difficulty modulating understand selvesselves sexual involvement Easily overwhelmed Excessive risk taking
Spinazzola 2010; CTTN Spinazzola 2010; CTTN conferenceconference conferenceconference
Behavioral Control BiologyBiology
Problems with Persistent medical Poor impulse control Social isolation coordination and complaints defying Excessive compliance SelfSelf--destructivedestructive balancebalance explanation behaviorbehavior Sleep disturbances Increased medical Phyyysical symptoms OOitilbhippositional behavior RfReenactment of problems across a replace their inability Aggression trauma in behavior wide spanspanwide to put words to their Substance abuse traumatic experience Eating disorders
Spinazzola 2010; CTTN Spinazzola 2010; CTTN conferenceconference conferenceconference
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Proposal to include Developmental C o g n itio n Cognition Trauma Disorder in the DSM V Bessel A. van der Kolk MD Robert Pynoos PD Learning difficulties Dante Cicchetti PhD Marylene Cloitre PhD Difficulties in attention Wendy D’Andrea PhD Problems focusing and completing tasks JliJulian For dPhDd PhD Alicia Lieberman MD Problems processing new information Frank Putnam MD Glenn Saxe MD Difficulty planning and anticipating Joseph Spinazzola PhD Bradley Stolbach PhD Martin Teicher MD PhD
Spinazzola 2010; CTTN conferenceconference
Alterations in Systems of Developmental Trauma Disorder MeaningMeaning (DTD)(DTD) A. Exposure. The child or adolescent has experienced or witnessed multiple or View the world through a dark lens prolonged adverse events over a period of Feel their lives do not make sense or have at least one year beginning in childhood or purposepurpose early adolescence , including: 1.1. Direct experience or witnessing of repeated Despair and hopelessness and severe episodes of interpersonal violence; and Doubt around ability to make positive 2.2. Significant disruptions of protective changeschanges caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to Spinazzola 2010; CTTN severe and persistent emotional abuse conferenceconference
Developmental Trauma Disorder
B. Affective and Physiological Dysregulation. The child exhibits impaired normative developmental competencies related to arousal Toward a new diagnosis . . . regulation, including at least two of the following: 1.1. Inability to modulate, tolerate, or recover from extreme affect states (e. g., fear, anger, shame), including prolonged and extreme tantrums, or immobilization 2.2. Disturbances in regulation in bodily functions (e.g. persistent disturbances in sleeping, eating, and elimination; overover-- reactivity or underunder--reactivityreactivity to touch and sounds; disorganization during routine transitions) 3.3. Diminished awareness/dissociation of sensations, emotions and bodily states 4.4. Impaired capacity to describe emotions or bodily states
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Key Treatment Planning Developmental Trauma Disorder Strategies for Complex C. Attentional and Behavioral Dysregulation: The child exhibits impaired normative developmental Trauma Intervention competencies related to sustained attention, learning, or 1.1. Comprehensive coping with stress, including at least three of the following:following: 2.2. AssessmentAssessment--DrivenDriven 1.1. Preoccupati on with th reat , or i mpa ire d capac ity to perce ive 3.3. Strength thStthss--bdbdbasedb d threat, including misreading of safety and danger cues 2.2. Impaired capacity for selfself--protection,protection, including extreme riskrisk-- 4.4. DevelopmentallyDevelopmentally--TailoredTailored taking or thrillthrill--seekingseeking
3.3. Maladaptive attempts at selfself--soothingsoothing (e.g., rocking and other 5.5. SystemicSystemic rhythmical movements, compulsive masturbation) 6.6. Culturally Adapted 4.4. Habitual (intentional or automatic) or reactive selfself--harmharm 5.5. Inability to initiate or sustain goalgoal--directeddirected behavior 7.7. EvolvingEvolving
8.8. PurposefulPurposeful Spinazzola 2010; CTTN conferenceconference
Modalities of Clinical Developmental Trauma Disorder Assessment: D. Self and Relational Dysregulation. The child exhibits impaired normative developmental competencies in their sense of personal ChildChild:: identity and involvement in relationships, including at least three of Parent/Caregiver:: the following: Behavioral observation Dyadic observation 1.1. Intense preoccupation with safety of the caregiver or other loved ones (including precocious caregiving) or difficulty tolerating reunion with Clinical interview Clinical interview them after separation SelfSelf--report measures 2.2. PPittersistent nega tive sense of flfildilf self, including self--loa thing, he lp lessness, SelfSelf--report measures worthlessness, ineffectiveness, or defectiveness Projective drawings 3.3. Extreme and persistent distrust, defiance or lack of reciprocal behavior Rater measures in close relationships with adults or peers Other (e.g., cognitive 4.4. Reactive physical or verbal aggression toward peers, caregivers, or other adults testing)testing) 5.5. Inappropriate (excessive or promiscuous) attempts to get intimate contact (including but not limited to sexual or physical intimacy) or excessive reliance on peers or adults for safety and reassurance
6.6. Impaired capacity to regulate empathic arousal as evidenced by lack of empathy for, or intolerance of, expressions of distress of others, or excessive responsiveness to the distress of others
Blaustein 2009
Complex Trauma Assessment and TreatmentTreatment Broad Domains of Assessment
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Assessing Child Needs: Assessing Strengths Symptom Expression Child strengths:
Posttraumatic symptoms (intrusions, Interpersonal
avoidance/numbing, hyperarousal) Educational/vocational
Talent/interests/hobbies
Spiritual/religious ClTComplex Trauma a dttidaptations Caregiver strengths:
Involvement/relatedness/supervision
Interpersonal “Other” psychiatric symptoms (attention, Cognitive/organizational depression, opposition, etc.) Environmental strengths
Stability/safety
Wider community involvement Blaustein 2009 Blaustein 2008
Assessing Child and Family Needs: Understanding History Assessing for PTSD Developmental history Trauma exposure(s) Placement history Relationship/caregiving history Periods of safety/danger Environmental support
Blaustein 2008
Assessing Current Coping Recognition of Posttraumatic Play PatternsPatterns DrivenDriven Aggressive behaviors Difficult to redirect SelfSelf--injuriousinjurious behaviors Repetitious and inalterable Sexualized behaviors Lack of enjoyment Substance or alcohol use/abuse May contain literal or symbolic aspects of trauma Less elaborated than most imaginative play HighHigh--risk/impulsiverisk/impulsive behaviors ReRe--traumatizingtraumatizing rather than anxiety-anxiety-relievingrelieving Dissociation Active Avoidance
Blaustein 2008 Blaustein 2008
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Attachment Classification: Secure PTSD Measures Attachment
Child Stress Disorders Checklist Caregiver Characteristics: Child Characteristics. Infants whose caregivers Their strategy for dealing TargetTarget: Acute and posttraumatic stress symptoms consistently respond to Observer rating scale with distress is distress in sensitive or ‘organized’ and ‘secure’. 36 items; 5-5-1010 minutes ‘loving’ ways, such as picking the infant up They seek proximity to promptly an d reassur ing and maintain contact with PTSD Reaction Index the infant, feel secure in the caregiver until they their knowledge that they feel safe. The strategy is The UCLA PTSD Index for DSMDSM--IVIV (UPID) (Pynoos, et al., 1998) is a revision of the can freely express Child PTSD Reaction Index: CPTSCPTS--RI.RI. It is a 4848--itemitem semisemi--structuredstructured interview that said to be ‘organized’ assesses a child’s exposure to 26 types of traumatic events and assesses DSMDSM--IVIV negative emotion which because the child ‘knows’ PTSD diagnostic criteria. will elicit comforting from exactly what to do with a the caregiver. sensitively responsive caregiver.caregiver.
van IJzendoorm, MH et. al. (1999)
Attachment Classification: Insecure AvoidantAvoidant
Caregiver Characteristics: Child Characteristics:: Infants whose caregivers Child avoids their consistently respond to Complex Trauma Assesement distress in insensitive or caregiver when ‘rejecting’ ways, such as distressed and minimize ignoring, ridiculing or disp lays o f nega tive becoming annoyed. emotion in the presence of the caregiver.
van IJzendoorm, MH et al (1999)
Attachment Classification: Attachment Resistant (ambivalent)
Caregiver Characteristics: Child Characteristics: The Strange Situation experiment Infants whose caregivers They display extreme respond in inconsistent, negative emotion to draw the unpredictable and/or ‘involving’ attention of their inconsistently ways, such as expecting the responsive caregiver. Strange Situation Experiment.mp4 - infant to worry about the caregiver’s own needs or by The strategygygy is said to be amplify ing the in fan t’s dis tress ‘organized’ because the child YTbYTbYouTube and being overwhelmed ‘knows’ exactly what to do with an inconsistently responsive caregiver, ie, exaggerate displays of distress and angry, resistant responses, ‘hoping’ that the response cannot possibly be missed by the inconsistently responsive caregiver.
van IJzendoorm et. al. (1999)
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Attachment Classifications: Assessment Indicators: Avoidant Disorganized Attachment Attachment
Conspicuous avoidance of proximity to or interaction with the mother One recently identified pathway to in the reunion episodes. Either the baby ignores his mother on her return, greeting her casually if at all, or, if there is approach and/or a children’s disorganized attachment less casual greeting, the baby tends to mingle his welcome with avoidance responses. turning away, moving past, averting the gaze, includes children’s exposure to specific and the like. Little or no tendency to seek proximity to or interaction or contact with forms of distorted parenting and unusual the mo ther, even in the reun ion ep iso des. caregiver behaviors that are ‘atypical’ If picked up, little or no tendency to cling or to resist being released. On the other hand, little or no tendency toward active resistance to Atypical caregiver behaviors, also referred contact or interaction with the mother, except for probable squirming to get down if indeed the baby is picked up. to as “frightening, frightened, dissociated, Tendency to treat the stranger much as the mother is treated, although perhaps with less avoidance. sexualized or otherwise atypical” Either the baby is not distressed during separation, or the distress seems to be due to being left alone rather than to his mother's absence.
Ainsworth, Blehar, Waters $ Wall LyonsLyons--RuthRuth et. al (1999) (1978)(1978)
Assessment Indicators: Resistant Attachment The baby displays conspicuous contact- and interaction- resisting behavior. Assessment of Classifications He also shows moderate-to-strong seeking of proximity and contact and seeking to maintain contact once gained, so that he gives the impression of being ambivalent to his mother. He shows little or no tendency to ignore his mother in the reunion episodes, or to turn or move away from her, or to avert his gaze. He may display generally "maladaptive" behavior in the strange situation. Either he tends to be more angry than infants in other groups, or he may be conspicuously passive.
Ainsworth, Blehar, Waters & Wall (1978)(1978)
Assessment: Indicators of Secure Other attachment related Attachment measures:measures:
The baby wants either proximity and contact with his mother or 1. Preschool Assessment of Attachment (PAA) interaction with her, and he actively seeks it, especially in the The PAA was devised by P.Crittenden for the purpose of assessing patterns of attachment in 1818-- reunion episodes. month to 5 year old children. Like the SSP it involves an observation which is then coded. The classifications include all the SSP categories plus patterns that develop during the second year of If he achieves contact, he seeks to maintain it, and either resists life. The three basic strategies for negotiating interpersonal relationships are modified to fit release or at least protests if he is put down. preschoolers and the patterns are renamed secure/balanced, or Type B, defendeddefended, or Type A and coercivecoercive or Type C. Disturbances of Attachment Interview (DAI) The baby responds to his mother's return in the reunion episodes 3. Child Attachment Interview (CAI) with more than a casual gggreeting-either with a smile or a cry or a This is a semi--structured interview designed by Target et al. (2003) for children aged 7 to 11. It is tendency to approach. based on the Adult Attachment Interview, adapted for children by focusing on representations of relationships with parents and attachment related events. Scores are based on both verbal and nonnon-- Little or no tendency to resist contact or interaction with his mother. - verbal communications. Little or no tendency to avoid his mother in the reunion episodes. 4. Attachment Interview for Childhood and Adolescence (AICA) He may or may not be friendly with the stranger, but he is clearly This again is a version of the Adult Attachment Interview (AAI) rendered age appropriate for adolescents. The classifications of dismissing, secure, preoccupied and unresolvedunresolved are the same as more interested in interaction and/or contact with his mother than under the AAI described below. with the stranger. 5. Parent Stress Index (PSI) He may or may not be distressed during the separation episodes, The PSI is a parent self-self-report,report, 101101--itemitem questionnaire, designed to identify potentially dysfunctional but if he is distressed this is clearly related to his mother's absence parentparent--childchild systems. An optional 19-19-itemitem Life Events stress scale is also provided. The PSI focuses intervention into high stress areas and predicts children's future psychosocial adjustment. There and not merely to being alone. exists a substantial body of published research linking PSI scores to observed parent and child behaviors and to child's attachment style and social skills Ainsworth, Blehar, Waters & Wall (1978)(1978)
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Assessment of Affect Expression: Blaustein and Kinniburgh (2005)
Assess the following areas: 1.1. Interest and openness to sharing internal Complex Trauma Assessment: Self experienceexperience RegulationRegulation 2.2. The ability to identify safe communication resources 3.3. The ability to initiate communication in an effective and goal oriented manner 4.4. Non verbal communication Skills 5.5. Verbal communication Skills 6.6. The use of Self Expression strategies
Affect: Primary Domains to Assess Assessment of Modulation: Blaustein and Kinniburgh (2005)
Primary Domains: Assess the following areas: 1.1. Current modulation strategies and the level of associated Identification: risk.risk. • Ability to identify internal experience and to accuratelyyy identifyyy emotions of others 2.2. Level of self awareness about the intensity of emotional experiiience Expression: 3.3. The ability to tune into and identify changes in affective • Ability to safely communicate emotional and/or physiological arousal. experienceexperience 4.4. The ability to experiment with a range of effective Modulation: coping/modulation strategies to elicit changes in arousal. • Ability to both experience and regulate emotions 5.5. The ability to use coping/modulation strategies to elicit successfully changes in arousal. 6.6. The level of support needed to implement strategies. Blaustein and Kinniburgh (2010)
Assessment of Affect Identification: Kinniburgh and Blaustein (2005) Cues of Impaired Modulation
Assess the following areas: Presence of: 1.1. Presence of Emotion Vocabulary. Numbing/avoidance DistractionDistraction 2.2. Range of Affect IsolationIsolation 3.3. The ability to connect emotion to internal cues Minimization Proj ecti ve id entifi cati on 4.4. The ability to connect emotion to external context. Alternate emotion 5.5. The ability to connect emotion to trauma triggers AggressionAggression and the danger response. Externalization (i.e., blaming others) Physiological regulation (jumping, running, fidgeting)
Sexualized behaviors
SelfSelf--harmharm
Substance use
Eating control/dyscontrol Blaustein 2008
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The Externalizing Child: Presentation Common Client Presentations Relies on a “front” to prevent others (and often, themselves) from awareness of vulnerability and damage due to a profound sense of mistrust in relationships.
Generally has access to “powerful” emotions – anger, injustice, blame – but little ability to Constricted acknowledge more vulnerable feeling states such as fear or sadness.
Often has deepdeep--rootedrooted sense of shame and self-self-blame.blame. Externalizing May readily acknowledge being angry at someone else, or upset about something that has Labile/explosive happened that day, but will deny feeling hurt or worried about the incident .
Emotion is generally connected to outside events, rather than their impact on the child.
Perceived injustice often a powerful trigger’
Presentation may be oppositional or argumentative with people in authority, although they are often able to build relationships with people they perceive as less threatening.
Appear to desire connection, but seek it in ineffective ways
Blaustein and Kinniburgh (2005) Blaustein and Kinniburgh (2005)
The Overly Constricted Child: Presentation
Often quiet, with difficulty initiating conversation, activities, and general interaction.interaction. The Externalizing Child
Difficulty describing emotions
Appear defended against emotional experience in general, and often lack an understanding of how to connect emotionally with others. (a)(a) Acknowledging and coping with vulnerable emotions. In younger children, may include failure to engage in imaginary play. PiPiPrimary (b)(b) Modulating intense emotion, particularly in the face of key triggers S kills Skills like injustice, shame, etc. May at times have explosive outbursts of emotion, in response to what appears DeficitsDeficits (c)(c) Accepting responsibility for actions in social conflict. to be minor stressors, as their intense control becomes overwhelmed or challenged. (d)(d) Empathy and perspectiveperspective--takingtaking in difficult relationships.
In the aftermath of this intense emotion, however, these children return quickly to a constricted state, and have difficulty acknowledging or processing the emotional experience.
Blaustein and Kinniburgh (2005) Blaustein and Kinniburgh (2005)
The Labile Child: Presentation
Presentation is changeable.
The Overly Constricted Child: Strongly affected by environmental triggers, others’ emotions, and internal states.
Clinical assessment is often complicated, because presentation can vary from day to day and hour to hour.
PrimaryPrimaryPrimary •• Limited emotional vocabularyyy Emotional reactions appear unp redictable , and may be disp ro portionate to the S kills Skills •• Limited skills to cope with and manage emotional experience, apparent stressor; child may go from 0 to 60 in a matter of moments, or completely DeficitsDeficits including positive emotions shut down just as quickly. (a)(a) Deficit in ability to seek social support, particularly in the sharing or management of emotional experience. These children’s lives are driven by emotion, but they have little cognitive framework for understanding it or ability to cope with it in healthy ways.
These children have frequently experienced interpersonal trauma over an extended period of time, and have relied heavily on dissociative coping.
Blaustein and Kinniburgh (2005) Blaustein and Kinniburgh (2005)
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The Labile Child: Considerations MeasuresMeasures
Child Behavior Checklist for Children
The Child Behavior Checklist (CBCL) was a parentparent--reportreport questionnaire on which the ••Modulating emotional experience (rapid escalation or numbing, with child was rated on various behavioral and emotional problems. It was first developed difficulty returning to baseline) PrimaryPrimaryPrimary by Thomas M. Achenbach and has been one of the most widelywidely--usedused standardized •• Misreading environmental cues; low threshold for perception of threat. measures in child psychology for evaluating maladaptive behavioral and emotional Skills Skills (a)(a) Inability to integrate experiences into a cohesive narrative and/or problems in preschool subjects aged 2 to 3 or in subjects between the ages of 4 and DeficitsDeficits sense of selfselfsense 18 Behavioral Assessment System for Children The BASC-BASC-22 is designed for use in evaluating children and adolescents with cognitive, emotional and/or learning disabilities.
Blaustein and Kinniburgh (2005)
Assessment Measures:
Adolescent Self-Self-RegulatoryRegulatory Inventory A 36-36-itemitem questionnaire used to measure the self regulation of teens. Complex Trauma Assessment: Trauma Symptom Checklist for ChildrenChildren-- Briere (1996) The Trauma Symptom Checklist for Children (TSCC) is a selfself--reportreport measure Alterations in Attention or of ‘post-‘post-traumatictraumatic distress and related psychological symptomatology’ in male and female children aged 8 –– 16 years16yearsyears. Consciousness
Fast Track Project Child Behavior Questionnaire This is a 20 item questionnaire designeddesigned to measure the self-self-regulationregulation skills of children and adolescents
Questionnaire on SelfSelf--RegulationRegulation Has 13 questions designed to assess children’s ability to regulate negative emotions and disruptive behavior, and to set and attain goals.
Signs and Symptoms of Dissociation in Children (from CDC)
Child does not remember or denies The voices may be friendly or angry and traumatic or painful experiences that are may come from “imaginary known to have occurred. companions” or sound like the voices of Child goes into a daze or trancetrance--likelike state parents, friends or teachers. at times or often appears “spaced out.” Child has intense outbursts of anger, Complex Trauma Assessment: Teachers may report that he orshe often without apparent cause and may “daydreams” frequently in school. display unusual physical strength during Child shows rapid changes in personality. thesethese Behavioral Control He or she may go from being shy to being episodes.episodes. outgoing, from feminine to masculine, Child sl eepwalk s f requentl y. from timid to aggressive Child has unusual nighttime experiences, Child is unusually forgetful or confused e.g. maymaye.g. about things that he or she should know, report seeing “ghosts” or that things e.g. may forget the names of friends, happen at night that he or she can’t teachers or other important people, loses account for (e.g. broken toys, possessions or gets lost easily. unexplained injuries). Child has a very poor sense of time. Child Child frequently talks to him or herself, shows rapid regressions in ageage--levellevel of may use a different voice or argue with behaviorbehavior self atatself Child continues to lie or deny misbehavior Child reports hearing voices that talk to even when the evidence is obvious. him or her.her.him Child has rapidly changing physical complaints.
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Measures of Self Perception in MeasuresMeasures Children/Adolescents
Trauma Symptom Checklist for ChildrenChildren-- Briere (1996) The Self-Self-PerceptionPerception Profile for Children (SPPC) (Harter, 1982,1985) This is a self-self-reportreport magnitude estimation scale that measmeasuresures a child's sense of general selfself--worthworth and There are 2 subscales that measure dissociative symptomatology including overt selfself--competencecompetence in the domain of academic skills Harter's instrument taps five specific domains of self-self- dissociation and fantasy. Items include; one’s mind going blank; emotional numbing; concept as well as global selfself--worth.worth. pretending to be someone else or somewhere else; dayday--dreaming;dreaming; memory problems and dissociative avoidance. The Perceived competence Scale (Harter, 1982) The PCSC is a self-self-reportreport measure of school competence in children.children. A teacher report form is also available. This instrument is also called the PSCS (Perceived SelfSelf--CompetencyCompetency Scale). The PCSC has 3 Adolescent Dissociative Exppperiences Scale competence domains: Cognitive ( school competence ), Social (peer--relatedrelated compp),yetence), and Physical This 30 item self report measure identifies experiences that an adolescent may or (sports competence), plus one subscale measuring general feelings of SelfSelf--worthworth (global competence). may not have and asks them to rate from 1 (never) to 10 (almost all the time) PiersPiers--HarrisHarris Self Concept Scale (second edition) Based on the child's own perceptions rather than the observations of parents or teachers, the The Child Dissociative Checklist PiersPiers--HarrisHarris 2 assesses selfself--conceptconcept in individuals ages 7 to 18. It is composed of 60 items The Child Dissociative Checklist(CDC) is a 2020--itemitem parent/adult observer report covering six subscales: Physical Appearance and Attributes; Intellectual and School Status; measure of dissociative behaviors. Happiness and Satisfaction; Freedom From Anxiety; Behavioral Adjustment; Popularity
Children’s Attributions and Perceptions Scale TargetTarget: Child attributions related to sexual abuse Age rangeAge range: 7 – 12 years12 years Clinician interview 18 items; 5 minutes
Complex Trauma Assessment: Self Complex PTSD Intervention PerceptionPerception
Complex PTSD Intervention Component Core Domains Core Components 1. SafetySafety1. ““ShameShame is the feeling of having a deficit of the self 2. Self-Self-RegulationRegulation (Body, Emotion, Behavior) that all can see yet one is helpless to correct. 3. Relational Engagement & Attachment (Working Models) There is no escapeescape-- 24hours a day, seven days a 4. Self-Self-ReflectiveReflective Information Processing (Attention, Narrative ReconstructionReconstruction——current/historical,current/historical, Executive FunctionsFunctions—— week,,p the shamed person lives with a sense of his anticipation, planning, decision--making)making)making) fatal flaws and unrelieved worthlessness” 5. Positive Affect Enhancement (Creativity, Imagination, Pleasure, Future Orientation, Achievement/Competence/MasteryAchievement/Competence/Mastery--seeking)seeking) 6. Trauma Experience Integration
Individualized Adaptations: Age/Development, Gender, Ethnocultural CrossCross--cuttingcutting Intervention Components: Psychoeducation, Screening/Assessment, Crisis Prevention/ Management, Trauma Recognition
NCTSN Complex Trauma Taskforce 2005 Linda T. Sanford (1991)
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Component 1: Component 2: SafetySafety SelfSelf--RegulationRegulation Clients who are unable to modulate arousal “The condition of being live in a body that experiences the constant safe from undergoing or threat of harm.
causing hurt, injury, or Affective arousal normatively serves as a cue for goalgoal--orientedoriented behavior and loss.”loss.” responseresponse MerriamMerriamMerriam –– WebsterWebster Rather than engaging in goalgoal--orientedoriented behavior, traumatized individuals experience arousal as a trigger for fight, “Freedom from danger, flight or freeze reactions in the absence of risk, or injury.” meaningful evaluation of experience American Heritage Dictionary Overwhelming levels of arousal lead to reliance on maladaptive (but immediately effective) coping strategies. All Safety is Relative Often the prime mover in this work, and the component to which early and continued intervention is most heavily directed
Why is it so important to build safety? SelfSelf--Regulation:Regulation: Targets
Clients who have experienced trauma often develop a SelfSelf--regulation:regulation: base expectation that the world is dangerous; as a result, they operate in “self“self--defense”defense” mode Affective, Behavioral, Somatic Clients will often experience threat as omnipresent: environment, relational danger, and internal distress may all be perceived as equally potentially threatening Self--soothingsoothing capacity
Perceptions of being unsafe is a profoundly somatic Up/down modulation of emotional states experience, and when chronic becomes hiredhired--wiredwired into the nervous system and imprinted on the body in ways that take a tremendous toll on the immune system, Healthy self-self-expressionexpression functioning and wellwell--beingbeing
Impulse control
Safety: Targets
Internal Safety: Ability to regulate and tolerate emotional experience Ability to modulate physiological arousal Ability to discriminate current fears from past danger Relational Safety: My First Yoga - Yoga for Kids - “Good enough” caregiving system Consistent response, safe limits, appropriate praise and reinforcement YouTubeYouTube Sufficient predictability Appropriate boundaries Physiological safety: Lack of reliance on selfself--harmfulharmful strategies to modulate experience (self(self--injury,injury, substances, food) Ability to tolerate experience sufficiently without death as viable option Understanding of body/somatic connection to stress and internal experience Therapeutic Safety: Trust, therapeutic alliance, safe boundaries, supportive/affirming environment Agency/System Level Safety:
TraumaTrauma--InformedInformed policies and procedures; common language; staff orientation and training; postpost--incidentincident stress management protocols;protocols; ongoing supervision; wellness initiativesinitiatives
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Component 3: Component 4: Relational Engagement SelfSelf--ReflectiveReflective Information ProcessingProcessing Internal reflection and meaningmeaning-- making, and external reflection and goalgoal--directeddirected behavior
Attachment allows Who am I?I?Who children to safely explore the world….. and provides a healthy How do I make meaning of the model for self and others world around me? How do I understand my experiences? How do I employ my cognitive processes so that I can act on Attachment is the dance of the limbic the world in an effective systems of the child and parent.” manner?manner? Allan Schore
Relational Engagement: SelfSelf--ReflectiveReflective Information TargetsTargets Processing: Targets Attachment/Caregiving System: Work with caregivers/providers to create a safe Executive functions: attention, environment that is able to support the person in anticipation, problem-problem-solving,solving, meeting emotional, and relational needs. planningplanning Build caregiver/milieu staff capacity to manage affect Build consistency in caregiver/milieu staff response to behaviorbehavior Coherent narrative of self and other Build caregiver/milieu staff capacity to build routines and ritualsritualsand Future orientation Interpersonal Connection: Build capacity to effectively build meaningful relationships with othersothers
Interpersonal Connection: Skill Component 5: TargetsTargets Positive Affect Enhancement Identification of safe communication resources
Include psychoeducation/processing of whywhy it is important to share emotional experience Effective use of resources
Initiating communication (Picking your moment, initiating conversation)
Using effective nonverbal communication (eye contact, physical space, tone of voice)
Verbal communication skills (“I” statements) SelfSelf--expressionexpression
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Positive Affect Enhancement: Component 6: TargetsTargets Trauma Experience Integration CreativityCreativity Imagination Understanding, accepting, Pleasure/Joy challenging, integrating and transcending difficult life Achievement experiences Competence MasteryMastery--seekingseeking
Project Joy's Steven Gross Direct TV Hometown Hero - YouTube What is “trauma processing” for a complexly traumatized client?
Playmaking in Haiti - March 2010 - Traumatic YouTubeYouTube Experiences Integration Memory Processing/ Exposure Therapies
NCTSN Complex Trauma Taskforce 2005
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Trauma Experience Integration: Complex TraumaTrauma--SpecificSpecific & TargetsTargets Compatible Interventions Comprehensive Treatment Frameworks Understanding how past experiences trigger current responses ARC (Attachment, Regulation & Competence) Containing traumatic reminders TST (Trauma Systems Therapy), Children’s Hospital Boston Differentiating fearful memories/body responses from current danger SAN CTUARY (Residential/Milieu Based)
Shifting from reactive to active lifestylelifestyle Complex Trauma Interventions CPP (Child Parent Psychotherapy), UCSF Building ability to live “in the moment” Real Life Heroes SPARCS (Structured Psychotherapy for Adolescents Responding to Chronic Stress)Stress) Addressing and mastering frightening experiences in a safe TARGETTARGET--A,A, (Trauma Affect Regulation: Guidelines for Education & Therapy for environment Adolescents) SEEKING SAFETY (Dual Diagnosis) Mourning losses Compatible Intervention Protocols Incorporating historical experiences into larger sense of self and identityidentity PCIT (Parent Child Interaction Therapy; TraumaTrauma--InformedInformed Adaptation) TAP (Assessment Based Treatment for Traumatized Children: Trauma Assessment Pathway) TFTF--CBTCBT (Trauma(Trauma--FocusedFocused Cognitive Behavioral Therapy), Alleghany General Hospital
Guidelines for Trauma Processing: 3 Levels of Engagement
1.1. Therapist recognizes trauma reactions and helps child & caregiver anticipate, prepare for and cope with these in daily lifelifein 2.2. Therapist teaches child & caregiver to recognize trauma reactions as ways of past adaptive coping to traumatic events; teach use of selfself--regulationregulation to modify unhelpful aspects of this coping 3.3. Therapist guides child & caregiver in storystory--buildingbuilding activities that enable child to recall and gain mastery in relation to memories of specific traumas
Ford, J. D., & Cloitre, M. (2008). Best practices in psychotherapy with children and adolescents. In C. Courtois & J. D. Ford (Eds.), Complex Traumatic Stress Disorders: An Evidence-Based Clinician's Guide. New York: Guilford Press.
Clinical DecisionDecision--MakingMaking about Level of Engagement of Trauma Processing
FirstFirst option is core to all psychotherapy for traumatized children
SecondSecond option is indicated in response to credible history of exposure + presence of adequate environmental stability for child to attend therapy and practice selfself--regulationregulation skills in a safe and supportive environment
ThirdThird option requires presence of a consistent and stable primary caregiver able to help the child work through this material; establishment of adequate selfself--regulationregulation capacity and environmental supports to tolerate distress without decompensation; a therapist with training and expertise in this work, as well as adequate psychiatric and crisis backback--upup
Ford, J. D., & Cloitre, M. ( 2008). Best practices in psychotherapy with children and adolescents. In C. Courtois & J. D. Ford (Eds.), Complex Traumatic Stress Disorders: An Evidence-Based Clinician's Guide. New York: Guilford Press.
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ARC - 10 Building Blocks
Trauma Experience Integration
Competency Executive Self Dev’t The ARC Framework Functions & Identity
Dev’tal Tasks Self- Regulation Affect Modulation Affect Identification Expression
Caregiver Routines Attachment Affect Attunement Consistent and Mgmt. Response Rituals Blaustein & Kinniburgh, 2010; Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005 Kinniburgh & Blaustein, 2005
Where does ARC come from? Who does ARC target?
Translation of clinical principles across settings Designed to target the needs of children, (out(out--px,px, residential, school, home-home-based)based) families, and systems impacted by complex
Or…what is it that we actually do? traumatrauma Core domains translate across children/ families/ “Evidence“Evidence--basedbased practice”? systems; applications and goals will vary
Or…how to fit real kids into scientific boxes Crucial importance of:
Keep an eye on the target, rather than the technique
Pay attention to relative goals and relative successes Staying true to the inner provider rr Have a plan, but catch the moments Or…keeping the art in trreea tta mentment
Blaustein & Kinniburgh, 2010; Blaustein & Kinniburgh 2010; Kinniburgh & Blaustein, 2005 Kinniburgh & Blaustein 2005
ARC principles have been used ARC Potential Components in…in… OutOut--patientpatient treatment Integration into clinical work (structured and InIn--patientpatient treatment unstructured); individual and/or dyadic Domestic violence shelters applicationapplication DV Advocacy programs Caregiver support (individual or group) Youth drop-drop-inin centers Caregiver training workshops Therapeutic foster care Group treatment Residential treatment / IRTP’s Group homes Milieu training, consultation, and staff support Juvenile justice facilities Milieu/systemic application Schools and Head Start programs CommunityCommunity--basedbased applications Child welfare training Importance of building an internal team to Early intervention support integration goals
Blaustein & Kinniburgh, 2010; Blaustein & Kinniburgh 2010; Kinniburgh & Blaustein, 2005 Kinniburgh & Blaustein 2005
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Treatments Utilized in the NCTSN 66--MonthMonth Change in CBCL Scores
17.4 68 TF-CBT 67 66 ARC 65 2.5 64 3.5 CPP 63 62 TF-CBT 61 4.5 PCIT ARC 60 SPARCS SPARCS 59 58 *Significant 8.3 63.8 57 Other / decreases Unknown 56 55 on CBCL 54 scores; no Total n=966 significant Baseline 3 Months* 6 Months* differences NCTSN FY 2010 Annual Progress Report – Executive Summary across NCTSN FY 2010 Annual Progress Report – Executive Summary interventions
66--MonthMonth Change in UCLA PTSDPTSD--RIRI ATTACHMENT ScoresScores
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23 TF-CBT ARC 21 19 *Significant decreases 17 on CBCL scores; no 15 significant Baseline 3 Months* 6 Months* differences across interventions NCTSN FY 2010 Annual Progress Report – Executive Summary
Attachment A Safe Relationship
Creation of a safe environment and Think about relationships in your own life. safe relationships that are able to Can you identify characteristics of those support children and adolescents in relationships (your attachment system) meeting all o f the ir nee ds. that make them safe?
Blaustein and Kinniburgh (2010)
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Primary Targets for building Attunement relational safety The Main Idea: Support the child’s caregiving system in learning to accurately Routines Attunement Consistent and and empathically understand and respond Response Rituals to children’ s actions, communications, needs, and feelings.
Caregiver Affect Mgmt. Attunement
Blaustein & Kinniburgh 2010; Kinniburgh & Blaustein 2005 Blaustein and Kinniburgh (2010)
DefinitionDefinition Attunement: Key Concepts
Children often communicate emotions and internal “To bring into a harmonious or experience via behavior, rather than words; traumatized children, in particular, may lack the capacity to responsive relationship” communicate their needs or even to know what those needs areareneeds
Attunement is the capacity to accurately read children’s cues and respond effectively to underlying emotion in service of regulation.
Blaustein and Kinniburgh (2010)
Attunement Relies on Engagement Primary Goals for Interventionist
No Child can learn without direct support 1. Attune to the caregiver and engage in reflective from their care giving system. listening.listening. Engage on mulitiple levels: through nonnon-- 2. Provide Psychoeducation for the Caregiver verbal cues, verbal engagement, task about: yyyouth behaviors and communications support and of course, play. 3. Teach Caregiver’s to become Feelings DetectivesDetectives Across levels of intervention (primary caregivers, staff, systems), pay attention 4. Attune to your client and engage in your own detective Process. to opportunities for positive engagement 5. Use attunement skills to support youth and interaction regulation and teach this to caregivers.
Blaustein and Kinniburgh (2010) Blaustein and Kinniburgh (2010)
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Active/Reflective Listening Skills
1. Accept and respect all of a child’s feelings. 2. Show child that you are listening. 1. Attune to the caregiver 3. Tell child what you hear him/her saying. 444. Label the feelings . 5. Offer advice/ suggestions/ reassurance/ onlyonly after helping child to express how he/she feels.
Blaustein and Kinniburgh (2010)
What helps the child survive?
2. Education to increase 1. Assumption of danger understanding of trauma behaviors. 2. Danger Avoidance: Rapid mobilization iithfn the face of percei ved dtht threat
3. Safety Seeking: Development of alternative strategies to meet needs
Blaustein and Kinniburgh (2010)
A2 – Primary Goals for Caregivers
3 & 4. Support the Caregiver in 1) OBSERVE & LISTEN: Build an understanding Becoming a Feelings Detective of child communication strategies.
2 REFLECT: Use Reflection to assess the situation and to teach affect identification skills in youth.youth.
3) VALIDATE & NORMALIZE:
4) RESPOND by offering tools rather than
advice.advice. Blaustein and Kinniburgh (2010)
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1. OBSERVE & LISTEN: Build an 1. OBSERVE & LISTEN: Build an understanding of youth understanding of youth “communication” “communication”
Support Caregiver’s Try to Figure out: in becoming a “feeling detective”. TRIGGERS Can do this as a prevention tool or in the moment. CUESCUES
COPING STRATEGIES
Blaustein and Kinniburgh (2010) Blaustein and Kinniburgh (2010)
2. REFLECT 3. Validate3. Validate
1.1. StopStop, Breathe, Look and Actively Listen Definition: “To declare the validity or truth 2.2. IgnoreIgnore the behavior and words for now of something”. 3.3. ActivelyActively observe your child’s cues 4.4. ShareShare your observations of cues PERCEPTION IS REALITY 5.5. Label: Put a possible label on what you see (i.e. Your energy looks high, you To Validate the clients experience does look uncomfortable?) not = accept their behavior.
Blaustein and Kinniburgh (2010) Blaustein and Kinniburgh (2010)
4. RESPOND: Support youth NormalizeNormalize Self Regulation
Provide responses to underlying need in support NormalizeNormalize the response: of regulation in a 2 step process:
1. Offer strategies to support the child in regulating ““It makes sense that yyyou are upset/your underlying affect. energy is high right now because your in a new place and that can be really hard” 2. Offer consistent responses to the behavior itself in a manner that is most likely to meet the underlying need.
Blaustein and Kinniburgh (2010) Blaustein and Kinniburgh (2010)
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Consistent Response
The Main Idea: Support the caregiving system in building predictable, safe, and YouTube -Still Face Experiment: appropriate responses to children’s behaviors, in a manner that acknowledggges DEddTikDr. Edward Tronick and is sensitive to the role of past experiences in current behaviors.
Consistent Response
Blaustein and Kinniburgh (2010)
Safe Attachment as the Context for Consistent Response Challenges with parenting may stem from: Caregiver’s own (perhaps understandable) Bob NewhartNewhart--StopStop It - YouTube difficulty managing affect in the face of child behaviorsbehaviors
Caregiver’s difficulty understanding child behavior and appropriately responding
Lack of awareness / knowledge of appropriate parenting skills
Blaustein and Kinniburgh (2010)
Three primary goals: Behavior Management Strategies
(1) Identify the current Function of the IgnoringIgnoring behavior: Danger Avoidance or Safety PraisePraise Seeking (primary need). Limit Setting (2) Respond to the behavior in a manner Time Out OutTimeOut that is MOST LIKELY to meet the current nee d. need. What do you think are important (3) Be consistent with this response for an considerations with each strategy when established time period in order to thinking about our traumatized youth? promote a sense of agency
Blaustein and Kinniburgh (2010)
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Therapy Examples Therapy Examples
M is a 15 year old girl who has a history of T is a 7 year old boy. He is new to the severe neglect. Reports suggest that she program. Has a history of complex trauma was left in her high chair alone in a closet including a history of aggressive sexual for hours at a time. abuse by an older male. M is having a difficult session. She is not T is doing his feelings check in and he tells following the structure of the meeting at you that he is feeling happy today. He all. all. gets up from his spot and comes over to She is picking up items in the office and your chair and begins to climb up onto gesturing self harm. your lap.
Parent Examples Parent Examples
M and T are the foster and pre-pre-adoptiveadoptive parents G is a 50 year old woman who has been a foster of a 13 year old boy with an identified history of parent for 25 years. Her foster child is 4 years severe neglect. They are first time parents and old and is struggling with multiple problems very eager to learn as much as they can about associated with PTSD. parenting. Her foster child often struggles durin g the Their 13 year old has a tendency to “lie” or often evening hours and consistently demonstrates has tremendous difficulty accepting tantrum behaviors at bedbed--time.time. responsibility for behavior such as hoarding G has stated that the child “just wants attention” food. and has chosen the management strategy of M and T have primarily focused on limit setting active ignoring. This strategy has not stopped and attaching consequences to “lying”. This has the initial tantrum although after approximately not lead to a decrease in behavior. 50 minutes the child does go to sleep.
A4 – The role of routines: Routines and Rituals Key Concepts Trauma is often associated with chaos and loss of The Main Idea: Build / enhance control; predictability helps build feelings of safety in predictability through the use of individual, traumatized children
familial, and systemic routines and rituals, When children feel safe, they are able to shift their in the service of increasing modulation and energy from survival to healthy development
felt safety for children and caregivers . Repetition is an important way that children gain skill; children often notice routines more in their absence than in their presence
Routines Routines should be part of the daily fabric, as well as and Rituals targeting areas of vulnerability or difficulty
Blaustein and Kinniburgh (2010) Blaustein and Kinniburgh (2010)
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A4 – Considerations in building A4 – Intervention targets routinesroutines
Incorporate routines into individual and group The primary goal is establishment of predictability in the service of modulation and felt treatment; balance structure and flexibility safetysafety Routines will naturally shift across time Build appropriate routines into home and Consider modulation in creation of routines (both systemic settings in daily rhythm, as well as incorporation of specific strategies Involve youth, as appropriate, in creation of Tune in to, explore, and (as appropriate) support routinesroutines the celebration of the rituals of a child, a family, Target areas of challenge (and predict / consider or a community the natural pitfalls)
Blaustein and Kinniburgh (2010) Blaustein and Kinniburgh (2010)
A4 – Therapy routine examples Examples of CheckCheck--InIn Activities
Point to face(s) on poster or handout that are closest Opening checkcheck--inin Feeling Faces to current feeling Draw a picture of "feeling(s) for today" Modulation activity Roll or toss a ball back and forth and take turns Ball toss telling one new thing that happened since previous Structured task session Have child name one good and one not-so-good Unstructured / free choice time Today's News thing that happened today; draw a picture or talk about it Closing checkcheck--outout / modulation activity Thumbs up / Pick one event from the past week – was it thumbs sideways / up (positive), thumbs sideways (neutral) or thumbs down down (negative)? Why? Clean upClean up Use thermometers, numbers, or other scales to Energy check check in on energy. Where is the child’s energy at Blaustein and Kinniburgh (2010) right now?
Closing CheckCheck--OutOut A4 – Home routines
Feeling What face (on the poster or handout) is closest now to child's Consider targeting: Faces feelings? What has changed? MealtimesMealtimes
Roll/toss ball back and forth; pick one thing each that you Ball Toss Play (“together time”, solitary time, peer-peer-toto-- liked or disliked about therapy today. peer time)peer time)
News Wrap- Keep a running list: what did child feel proud of in therapy TransitionsTransitions up today? ChoresChores
Thumbs up / What was the child’s favorite or least favorite thing from HomeworkHomework down today’s session? Family together-together-timetime Where is child’s energy now? Is it the same or different as Energy check BedtimeBedtime at the start of session?
Blaustein and Kinniburgh (2010) Blaustein and Kinniburgh (2010)
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SELF REGULATION SelfSelf--RegulationRegulation
Overarching goal: Work with children to build ability to safely and effectively manage experience on many levels: emotional, physiological, cognitive, and behavioral; this includes the capacity to identify, access, modulate, and share various aspects of experience
Blaustein and Kinniburgh (2010)
Domain 2:Domain 2: Affect Identification: SELFSELF--REGULATIONREGULATION The Main Idea: Work with children to build an awareness of internal experience, the ability to discriminate and name emotional states, and an Affect Affect Modulation undtdifhthttderstanding of where these states come from. Identification Expression
Affect Identification
Blaustein and Kinniburgh (2010) Blaustein and Kinniburgh (2010)
Primary Targets
LanguageLanguage for emotions and energy / Domain 1:1:Domain arousalarousal Identification of Emotion In Others Connection amon ggg,y feelings, body sensations, thoughts, and behaviors; understanding the links, and using these as “clues” to understand experience ContextContext: understanding experiences that elicit emotions and arousal
Blaustein and Kinniburgh (2010)
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Affect Identification - Other 4 Primary Intervention Strategies:
Identifying emotions in others: relies on 1. Normalization ability to accurately read cues such as body language, voice tone, eye contact, 2. Use of Displaced Affect and other cues such as behavior and ultimately to connect this to context. 3. Use of Visual Cues
4. Caregiver Modeling
Blaustein and Kinniburgh (2010) Blaustein and Kinniburgh (2010)
2. Use of Displaced Affect: Reflect 1. Normalization and Inquire about . . ““SomeSome Kids Feel {Sad, Mad, Worried, Disappointed, etc} when their familyyy doesn’t show for a visit”.visit”.
Blaustein and Kinniburgh (2010)
2. Displaced Affect: Use of Media 3. Use of Visual Cues
Lion King -Sad Moon [For Sarabii..] - YouTubeYouTube
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4. Caregiver Modeling
Caregivers act as modelsmodels and primary teachers of affect in Domain 2:2:Domain other by:by:other Iden tify ing Emot i on s in SeSeSelf 1. Naming Affect 2. Naming Cues 3. Implementing and naming coping strategies.strategies.
Blaustein and Kinniburgh (2010)
Goal: Develop a language for There are 2 Primary Intervention experienceexperience StrategiesStrategies Awareness of internal experience moves in stages, from basic to more sophisticated 1. Attunement and Reflection Basic identification is simply about helping children pu t a lbltthilabel to their exper ience. 2. Routine Check In’s/Out’s
The primary initial goal is to support children in developing an awareness of and language for internal emotional and physiological experience. Pay attention to language for energy and arousal, as well as emotion.
Blaustein and Kinniburgh (2010) Blaustein and Kinniburgh (2010)
1. Using Attunement/Reflection to 2. Using Routines to teach Affect teach Basic Language Identification Actively Observe and share observations Incorporate a “check in” into the beginning of affect in the child. Help verbal children of the day and a “check out” into the end to find words for their experience: of the day. With very young children and DD youth it Attach labels to feelings and or Energy. is important to use concrete, non verbal prompts/cues to support this process.
Start with Basic Less Vulnerable Feelings like tired, hungry, happy etc.
Blaustein and Kinniburgh (2010) Blaustein and Kinniburgh (2010)
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Goal: Enhance Understanding of 3 Primary Intervention Strategies Experience Advanced Affect Identification incorporates 1. Attunement and Reflection two primary targets: 2. Consistently Response/Visual Cues Understanding the connectionconnection of emotions to other aspects of experience (“I know I’m feeling happy because….”) 3. Consistent Response/Energy/Body Mapping.Mapping.
Understanding the context of emotion (“The reason I’m feeling happy is….”)
Blaustein and Kinniburgh (2010) Blaustein and Kinniburgh (2010)
1. Using Attunement/Reflection 2. Using Consistent Response to teach Advanced Affect Identification
Actively Observe and share observations of Teach Caregivers to use feelings faces affect in the child. Help verbal children to find words for their experience: For example: when a “contextualizing event” occurs. . -- “you are so jumpy, giggly and smiley today. Consider events such as anniversary’s, What are you feeling? ” transitions, an occurrence of a stressor , -- “you are asking a lot of questions about your incident, etc. visit today”today”visit -- “you need me to tell you are doing a good job a lot today”today”lot -- “your head hurts and your belly aches today”
Blaustein and Kinniburgh (2010) Blaustein and Kinniburgh (2010)
3. Energy/Body ModulationModulation MappingMapping Show me where you feel The Main Idea: Work with children to develop Happy? Sad? safe and effective strategies to manage and Where is Your Energy Right regulate physiological and emotional now? What Do you notice: experience, in service of maintaining a --FeelFeel your heart beat comfortable and effective state of arousal. --AreAre you hot, ok, cold? --DoDo your muscles feel like uncooked or cooked spaghetti? Affect --AreAre you breathing? Fast, Modulation Medium or Slow?
Blaustein and Kinniburgh (2010) 1.7 Blaustein and Kinniburgh (2010)
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ModulationModulation ModulationModulation Modulation Involves Multiple Skills:: 4 Specific Targets / Skills:
Ability to identify initial emotional/physiological state 1. Support caregiver/youth in identifying current modulation strategies both adaptive and maladaptive. Ability to identify and connect to subtle changes in state. A note about connectionconnection: This is the ability to tune intotuneintointotune into,,, 2. Build caregiver/youth understanding of comfortable toleratetolerate, and sustainsustain connection to and effectiveeffective states emotional/physiological states. 3. Supporting Modulation through dyadic engagement Ability to identify what it feelsfeels like in the body to experience subtle changes in state 4. Teach the caregiver to support children in exploring arousal states, and in developing a sense of agency over Ability to identify and use strategies to manage those tools that allow them to manage emotions and energy state changes (build a “feelings toolbox”).
Blaustein and Kinniburgh (2010) Blaustein and Kinniburgh (2010)
1. What are child/adolscent’s Psychoeducation with Current Coping Strategies? Sexually Reactive Behavior The Caregiver and/or Isolating/Avoidance Shutting Down completely ChildChild Somatic expression Head Banging 1.1. Identify current Modulation Rocking/Rhythmic movement StrategiesStrategies Thumb Sucking Reenactment 2.2. Identify current comfort Zone MovementMovement
Blaustein and Kinniburgh (2010)
2. What is Comfortable and +10 Effective?Effective? The POWER zone – Individual living in hyperarousal +9 Normalize and teach the concept of “energy” +8 Differences: +7 Link energy with feelings THE ROLLER- +6 Build an understanding of degree of emotion or The Comfort COASTER – +5 energyenergy Comfort ZoneZone zone? What +4 Build an understanding of “Comfort Zone” comfort zone? +3 Build an understanding of the role of context +2 Build a sense of agency over modulation: Build a +1 toolboxtoolbox The KEEP-IT- COOL zone – any 0 arousal is scary -1
Blaustein and Kinniburgh (2010) Blaustein and Kinniburgh (2010)
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Sensory Interventions to Support 3. Supporting Modulation ModulationModulation through Dyadic Engagement The brain teaches us to look, listen, smell, touch and taste The experience of events is multimodal involving both sensory and motor systems PlayPlay Individuals with trauma histories, mental health Mirroring disorders or developmental disorders often are unaware of their sensory diets CoCo--RegulationRegulation
Blaustein and Kinniburgh (2010) Lary 20112011Lary
Main Goals of Sensory Types of Sensory Inputs Interventions Tactile/ Touch 1.1. To help regulate arousal 2.2. Help orient, ground and calm individuals 3.3. To he lp bu ild to lerance for grea ter arousal while maintaining effective functioningfunctioning 4.4. Help build mastery and regain control
Lary 2011Lary 2011
Types of Sensory Inputs Types of Sensory Inputs
Deep Pressure SmellSmell
•• LotionsLotions
•• FoodFood
•• Body spraysprayBody
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Types of Sensory Inputs 4. Exploring Arousal States to build a comfortable and SoundsSounds effective TOOLBOX
Up/Down Regulation Activity Examples Building a Toolbox
4. Building the Toolbox Breathing: Example Activities
Early Middle Adolescence/ Overarching Goal: Work with children to Childhood Childhood Adult try out/experiment with different sensory Bubble London Bridges Diaphragmatic based activities to build a concrete Breathing Breathing “toolbox” (lists or actual box) that cues children to use specific coping skills for Pillow Breathing Imagery Pair with Visual specific emotion states. Imagery
Blaustein and Kinniburgh (2010)
Movement: Example Activities Grounding: Example Activities
Grounding – Down-regulation: General Note on Movement: Almost any kind of movement can be used. Have Fun! Early Middle Adolescence/ Early Middle Adolescence/ Childhood Childhood Adult Childhood Childhood Adult Tactile stimuli: Handheld Abstract •Hop like frogs •Challenges: •Go for a walk manipulatives: Techniques: •Head, with exercise •Toss a ball Magic rocks Shoulders, •Dance: Go back and forth Piece of velvet Stress Balls Mental Tasks Wikki Stix Music Knees and from slow to fast •Go to the Gym Stuffed animal Lanyard string Writing or Drawing Toes •Play Simon •Do exercise •Hokey Pokey Says or other games
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Muscle Relaxation: Example Grounding: Example Activities ActivitiesActivities Grounding – Up-Regulation: Early Middle Adolescence/ Early Childhood Middle Childhood Adolescence Childhood Childhood Adult •Play “I spy” •List 10 things •Tune into physical Robot/Rag Doll Curl and Tense and •Glitter cream they see in th e sensations RlRelease RlRelease •Self hugs office • 4, 3, 2, 1 thing •Dig a hole with •Describe favorites they hear, see or their toes •Squeeze stress feel Caterpillar/ Doorway Pair with ball •Step by Step Butterfly Stretch Breathing
Example: Tracking Energy
Start Point: How do you feel right now? What are you noticing in your body? Jot a few notes: ______
Rate your energy level right now on the following scale: ______--11 0 1 2 3 4 5 6 7 8 9 10 Shut Low energy/ Moderate High energy/ Down Calm Energy Intense Emotion
Activity 1Activity 1: Activity: ______Starting arousal level: ____ Ending arousal level: ____ Reactions: ______ It is important to track either formally or unformally and reflect this to the childchild
Helpful Hints for the Caregiver Do as much as child will let you do: Some kids crave it and others avoid it so need to meet child where they are and ease ineaseinin Case Application: Caregivers should be supported in building a “toolbox” of items. Build this into natural play and engagement as much as possible (Remember Attunement/ Routines)
Lary 2011Lary 2011
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Case # 2: Jamie JamieJamie Primary skills deficits: Presentation: Acknowledging and coping with vulnerable emotions Access to the “power” emotions and cognitive states Modulating intense emotion, particularly in the face of (i.e., anger, blame), but little ability to acknowledge or key triggers such as injustice and shame tolerate more vulnerable emotions (i.e., fear, Modulating and managing behavior in the face of sadness)sadness) intense emotion Emotions and behaviors are connected to (and the Accepting responsibility for actions in social conflict result of) external events, and the child owns little Engaging empathy and perspectiveperspective--takingtaking in responsibility for them (“If he hadn’t made me so mad relationships I wouldn’t have hit him.”) Injustice is a powerful trigger Function of externalizing adaptation: A common Relationships with others may be marked by presentation among children like Jamie with a badly “oppositional behavior” (i.e., attempts to exert and test damaged sense of self, this adaptation allows children to control); there is a profound sense of mistrust in protect themselves from overwhelming, distressing relationship, and these children will “test” emotion; because skills to cope with intense affect are relationships, expecting rejection and/or limited, there is no tolerance for thoughts or feelings that abandonment threaten their fragile sense of self
Case # 3: Emma
Presentation:
Presentation shifts often and quickly; child is strongly affected by Possible Treatment environmental triggers, others’ emotions, and internal states. Child may at times appear wellwell--putput--together,together, and at other times GoalsGoals reactive, withdrawn, or overwhelmed. Emotions and energy are un predictable , and child may vacillate between hyperhyper-- and hypo-hypoand -arousedaroused states
Distress is experienced as diffuse and overwhelming. Although Affect Identification: the full range of emotion is experienced, there is difficulty differentiating among degrees (i.e., sadness versus despair; Affect Modulation: irritability vs. rage) Emotional states (and therefore sense of self) may be fragmented from each other: when experiencing an emotional state, the child has difficulty thinking past it; when out of the state, the child may deny or have difficulty accessing it
EmmaEmma
Primary skills deficits: Highly active “alarm system”; low threshold for perception of threat, and overestimation of danger Possible Treatment Inability to modulate emotional experience, across types of feelings; rapid escalation and/or constriction GoalsGoals Function of labile adaptation: This adaptation occurs as a result of a heightened biological alarm system, which originally arose to protect the child from frequent/ongoing Affect Identification: danger. In the present, a wide range of both external experiences and internal sensations may be experienced Affect Modulation: as threatening, and trigger this alarm system. In the absence of an organized strategy, arousal level swings through the full range of hypohypo--to hyperhyper--arousal.arousal.
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Expression: R3 –Key Skills and Targets
Exploration of the goals of expression; The Main Idea: Help children build the build comfort and safety in relationship skills and tolerance for effectively sharing emotional experience with others Identifying resources for safe expression Effectively using resources
Initiating communication Affect Effective nonverbal communication skills Expression Effective verbal communication skills Building and supporting forums for selfself-- expressionexpression
VT: The Definition
Taking Care of the Caregiver: The “. . .the stress resulting from Foundation of relational safety helping or wanting to help the traumatized or suffering person.”
Caregiver Affect Mgmt.
Signs of Parental Burn Out Caregiver Affect Management
Irritability and testiness.. The Main Idea: Support the child’s Resentfulness, a lack of joy, guilt, anger and caregiving system in understanding, feelings of frustration and inadequacy.. managing, and coping with their own
FatigueFatigue emotional responses, so that they are better able to support the children in their Withdrawal, detachment or a lack or care.care. "presence" with your children.. Caregiver Affect Mgmt.
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Why Trauma challenges caregivers Common Caregiver Responses
Being triggered by caregivers Feeling ineffective Displaying anger and opposition Guilt and Shame DditttiDemanding attention Anger, blaming the child Withdrawing from the child Cycle of approach and rejection Overreacting Extreme reactions Becoming overly permissive Witnessing pain Disrupting placement Blaustein, M. & Kinniburgh, K. (2010)
Things that activate our push buttonsbuttons
Low energy
HistoryHistory
BlifBlifBeliefs
Expectations
FearFear
The Trauma Cycle Youth Caregiver / Staff Provider Put on your oxygen mask first Cognitive I am bad, I am ineffective. I am ineffective. unlovable, damaged. This kid is causing trouble. This family/ this parent is To step out of the cycle, caregivers must He’s making things so difficult. They need to People are chaotic for everyone. just do what I ask them first regulate their own emotional dangerous. I can’t to do. trust anyone. experience. Emotiona Shame, Anger , Frustration, Anxiety , Frustration, anger, l Fear, Helplessness burnout, loss of empathy Hopelessness Behavior Avoidance, Over-reacting, Controlling, Reactivity, control, (Coping aggression, pre- Shutting down / punitive responses Strategy) emptive rejection Disconnecting emotionally. and self-protection. The “I’m being “He keeps fighting me; I “I have to up the ante or Cycle controlled; I have better dig my heels in.” this family will never do to fight harder.” “This provider doesn’t get the right thing.” it – I’m not going to bother.”
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A1 – How do we increase our Normalize and Depersonalize ability to regulate? Primary Targets (1) Validation, psychoeducation and depersonalization Normalize caregiver response to difficult Normalizing caregiver responses and depersonalizing youth behaviors – we feel what we feel behaviors / reactions
(2) Assess push buttons or difficult situations Depersonalize youth trauma response Building awareness of challenging situations
(3) Self-Self-monitoringmonitoring skills Provide and seek psychoeducation about: Increasing capacity to “tune in” to our own reactions • Adaptive nature of behaviors • Understanding function of child behavior (4) Self-Self-carecare and support • Understanding and recognizing triggers (and differentiating this response from opposition, manipulation, etc.) Building coping strategies and support systems that facilitate caregiver selfself--carecare • Working models of self and other, including the parallel processprocess
Assess Push Buttons: Identifying Build Self-Self-MonitoringMonitoring Skills Difficult Situations
Build self--monitoringself monitoring skills: Work with adults to notice their Consider the following with all adults: own typical responses to difficult situations
How are you coping? What sustains you in BodyBody: What cues does the body give? Notice more routine body cues, as well as warning signs for “losing control” or hitting a danger (parenting, your work), and what feelings do you pointpoint
find harder? ThoughtsThoughts: What are caregiver’s automatic thoughts in the face of difficult situations? Do they….blame themselves? Worry about their Are there particular vulnerable areas? choices? Focus on what the child is not doing? Compare the child to • i.e., Specific youth behaviors that are more difficult to cope with other kids?other kids?
or that “push your buttons”, times of day or times of year (i.e., EmotionsEmotions: What does caregiver feelfeel in the face of these thoughts? holidays, transition times, etc.) How strongly?
How do you know when you are modulated versus on BehaviorBehavior: What do you do in challenging situations? Withdraw? Become punitive? Freeze? Learn to recognize behavioral coping edge?edge? strategies.strategies. What other types of things affect your ability to stay centered (i.e., external pressures, lack of sleep, etc.)?
Tune into Your Experience SelfSelf--CareCare and Support
Each caregiver should have a “self“self--care”care” plan, including an YouTube -Precious staircase fight scene individual “tool“tool--box”box” Pay attention to both inin--thethe--pocketpocket techniques and more ongoing self-self-carecare and support) Individual Level Examples:: ••CoCoppgpging tools: Deep breathing Muscle relaxation/stretching/neck rolls Distraction: shifting off of unproductive thoughts Take a break – time out Individual “mantra” • Preventative: ongoing self-self-carecare plan • Connection to concrete community resources Group/family Level:: ••SelfSelf--carecare forums (i.e., exerciseexercise group, yoga groups) • Fun family activities • Caregiver- Caregiver-toto--caregivercaregiver support Blaustein & Kinniburgh 2010; Kinniburgh & Blaustein 2005
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“Talk to your kid and don’t hover over them. Give them space. They will come to you when they are Youth Speak to Families ready”.ready”. “ Tell them that yyyou love them a lot but don’t be like hovering over them and show that you love them and are
PYFC Committee, NCTSN (2008)
“Don’t give up on hope that they are gonna get better. Just believe and trust that they are gonna ”Don't give up. It's easy to think you can't make it—it— get better. Everything’s gonna be ok. There are but you gotta keep tryingtrying——andand you can make it—it— people who have been through the same thing and just don't give up. If you give up, then it's all over”. they have been ok. Have faith that things will be ok”.ok”.
“People need to have a CHOICE of therapists. This information needs to be provided at the beginning of treatment, so the youth knows that if Youth Speak to Providers: their first therapist is not a good fit, they can ask flIfor someone else. Itt iits necessary to ffleel a connection in some way with a therapist. Youth may want to find a therapist with ‘my style’.”
PYFC, NCTSN (2008)
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“Honesty is the most important thing, by far. You “What's important about treatment provider and have to be honest with your counselor and your the youth is that the therapist should know his/her counselor has to be honest with you. You might patient and not just look at this child as a "patient" hear things you don't really want to hear, but but as someone that has been through something sometimes those are the most important things”. tragic whatever the situation”. “If your counselor isn't honest with you, the “I’m not saying get emotionally attached but counseling is a waste of time, because you know understand that [he or she is] a human and not a you can't really believe what they say”. "patient" or a "victim“”.
Resilience relies on the caregiver’s ability . . . Core values that drive Trauma To Foster informed care
To Develop To Hope
Kinniburgh 2012
“To Foster” . . . “To Develop”
To encourage or promote the development of some thing. (some thing tha t is typ ica lly “To b ri ng out th e capabiliti es or regarded as good) possibilities”
Synonyms: To raise, to cherish, to nurture
Kinniburgh 2012 Kinniburgh 2012
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“To Hope”“To Hope”
Children are not simply a composite of their deficits, but are whole beings, with strengths, vulnerabilities, challenges, “T“ To b e lieve in a pos itive and resources. outcome”outcome”
Blaustein & Kinniburgh, 2010; Kinniburgh 2012 Kinniburgh & Blaustein, 2005
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23 WHAT ARE YOUR PUSH BUTTONS?
1.
2.
3.
4.
5.
HOW DO YOU COPE WITH YOUR PUCH BUTTONS
Example: I try to control the situation and become more punitive Example: I shut down and give up Example: I count to 10
1.
2.
3.
46 46 HOW CAN YOU COPE WITH YOUR PUSH BUTTONS: SELF CARE PLAN
Example: Take 3 deep breaths Example: Use positive self talk Example: Switch out with another staff member
IN THE MOMENT: 1.
2.
3.
WHEN YOU GO HOME:
1.
2.
3.
47 47 CHECK YOURSELF
Take a moment to ask yourself the following questions:
What is my body telling me?
What am I feeling right now?
What am I thinking right now?
What do I want to do right now?
What can I do right now?
48 48 You Tube Video Clips- Kinniburgh Presentation
http://www.youtube.com/watch?v=aDxD2YByp3g
http://www.youtube.com/watch?v=nrUY9agwDpg&feature=related
http://www.youtube.com/watch?v=apzXGEbZht0
http://www.youtube.com/watch?v=Ow0lr63y4Mw
http://www.youtube.com/watch?v=Gp3oq9s4ar0&feature=related
http://www.youtube.com/watch?v=4JXmQc3_m_k
49 49 References
Ainsworth, Blehar, Waters & Wall (1978) , Patterns of attachment. Hillsdale, NJ: Erlbaum. The commentary and the similarity matrix are my own.
Alink, L., Cicchetti, D., Kim, J. & Rogosch, F. (2009). Mediating and moderating processes in the relation between maltreatment and psychopathology: Mother-child relationship quality and emotion regulation. Journal of Abnormal Child Psychology, 37(6), 831-843.
Anda, R. F., Croft, J. B., Felitti, V. J., Nordenberg, D., Giles, W. H., Williamson, D. F., et al. (1999). Adverse childhood experiences and smoking during adolescence and adulthood. JAMA: Journal of the American Medical Association, 282(17), 1652-1658.
Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C., Perry, B. D., et al. (2006). The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology.
Anderson, S. W., Damasio, H., Tranel, D., & Damasio, A. R. (2001). Long-term sequelae of prefrontal cortex damage acquired in early childhood. Developmental Neuropsychology, 18(3), 281-296.
Arvidson, J., Kinniburgh, K., Howard, K., Spinazzola, J., Strothers, H., Evans, M., Andres, B., Cohen, C. & Blaustein, M. (2011). Treatment of complex trauma in young children: Developmental and cultural considerations in applications of the ARC intervention model. Journal of Child and Adolescent Trauma, 4, 34-51.
Benoit, D. (2004). Infant-parent attachment: Definition, types, antecendants, measurement and outcomes. Pediatric Child Health, 9(8), 541-545.
Blaustein, M. & Kinniburgh, K. (2007). Intervening beyond the child: The intertwining nature of attachment and trauma. Briefing Paper: Attachment Theory Into Practice. British Psychological Society, Briefing Paper 26, 48-53.
Blaustein, M. & Kinniburgh, K. (2010). Treating traumatic stress in children and adolescents: How to foster resilience through attachment, self-regulation, and competency. New York: Guilford Press.
Cicchetti, D., Rogosch, F. A., & Toth, S. L. (2006). Fostering secure attachment in infants in maltreating families through preventive interventions. Development and Psychopathology, 18(3), 623-649.
Cicchetti, D. & Rogosch, F. (2009). Adaptive coping under conditions of extreme stress: Multilevel influences on the determinants of resilience in maltreated children. New Directions in Child and Adolescent Development, 124, 47-59.
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Cook, A., Spinazzola, J., Ford, J. D., Lanktree, C., Blaustein, M., Cloitre, M., et al. (2005). Complex trauma in children and adolescents. Psychiatric Annals, 35(5), 390-398.
Ford, J., Stockton, P., Kaltman, S. & Green, B. (2006). Disorders of Extreme Stress (DESNOS) symptoms are associated with type and severity of interpersonal trauma exposure in a sample of healthy young women. Journal of Interpersonal Violence, 21(11), 1399-1416.
Courtois, C. & Ford, J. (Eds.) (2009). Treating complex traumatic stress disorders: An evidence-based guide. New York: The Guilford Press.
James, B. (1989). Treating traumatized children. New York: Free Press.
Kinniburgh, K., Blaustein, M., Spinazzola, J., & van der Kolk, B. (2005). Attachment, Self-Regulation, and Competency: A comprehensive intervention framework for children with complex trauma. Psychiatric Annals, 35(5), 424 - 430.
Kinniburgh, K., Hodgdon, H., Gabowitz, D., Blaustein, M. & Spinazzola, J. (2012, submitted). Development and implementation of trauma-informed programming in residential schools using the ARC framework
Hughes, D. (2007). Attachment-focused family therapy. New York: W.W. Norton & Co.
Kinniburgh, K., Blaustein, M., Spinazzola, J., & van der Kolk, B. (2005). Attachment, Self-Regulation, and Competency: A comprehensive intervention framework for children with complex trauma. Psychiatric Annals, 35(5), 424 - 430.
Lyons-Ruth, K., Dutra, L., Schuder, M. & Bianchi, I. (2006). From infant attachment disorganization to adult dissociation: Relational adaptations or traumatic experiences? Psychiatric Clinics of North America, 29, 63-86.
Masten, A. S., & Coatsworth, J. D. (1998). The development in competence in favorable and unfavorable environments. American Psychologist, 53(2), 205-220.
Masten, A.S. (2001). Ordinary magic: Resilience processes in development. American Psychologist, 56, 227-238.
Matthews, W. (1999). Brief therapy: A problem-solving model of change. The Counselor, 17(4), 29-32.
McCann, I. L. & Pearlman, L. A. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3, 131-149.
51 51 Putnam, F. (1997). Dissociation in Children and Adolescents. New York: The Guilford Press.
Putnam, F. W. (2008). The Longitudinal Effects of Childhood Sexual Abuse Over Three Generations: Implications for Treatment and Intervention. Paper presented at the International Trauma Conference.
Tronick, E. (2007). The neurobehavioral and social-emotional development of infants and children. New York, NY US: W W Norton & Co.
van der Kolk, B. (2005). Developmental Trauma Disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35(5), 401-408.
van der Kolk, B., Roth, S., Pelcovitz, D., & Mandel, F. S. (1994). Disorders of extreme stress: results from the DSM IV field trial for PTSD. Unpublished manuscript.
Centers for Disease Control and Prevention (2005). Adverse Childhood Experience Study, Prevalence of Individual Adverse Childhood Experiences. Retrieved 7/10/08 from http://www.cdc.gov/nccdphp/ACE/prevalence.htm
52 52 Case Vignette ~ Emma
Demographic Information ~ Emma is a 3 year old girl living in an adoptive home with her adoptive mother and father and their 2 year old biological daughter. Emma came into child protective services custody at 6 months due to substantiated severe neglect and chronic exposure to domestic violence.
Presenting Concerns ~ Emma presents as very emotionally reactive and clingy. Emma experiences severe tantrums and places enormous demands on her adoptive parents for constant attention. After visits with her mother, Emma is alternatively dissociative and emotionally reactive. Anytime her adoptive mother tries to leave Emma completely falls apart. Monday mornings (when adoptive Dad returns to work) she cries for hours saying “Daddy no leave…please no leave me.” Emma is alternatively disconnected and blank or emotionally reactive after visits with her mother. Her adoptive mother says “I’m not sure how long I can keep this up.”
Developmental History ~ Much is unknown about Emma’s first 6 months of life except that both of her parent’s experienced chronic substance abuse problems, there were multiple reports to child protection, and at 6 months Emma was taken into protective services custody when she was discovered by police in her crib, underweight, covered in feces and her father was unconscious (substance induced) and her mother was gone. Several attempts at reunification and placement with relatives were made but ultimately were unsuccessful. Ongoing reports of harm occurred during these attempts at reunification. Child protection is currently pursuing termination of parental rights and adoption. Emma visits with her biological mother 2 times per week typically at a local shopping center. During these visits her mother is distracted or on her cell phone, Emma walks several feet behind her mother, staring off into space. After visits she is volatile and reactive.
Current Presentation/Functioning Interpersonal and Social Emotional ~ Emma’s adoptive parents report feeling exhausted by Emma’s need for constant attention, difficulty soothing, and the ease with which she is triggered by environmental cues. Emma’s adoptive mother says that when they pass a store Emma is triggered and remains distressed for an hour or more. Emma’s adoptive mother also reports that when her husband leaves for work Emma falls apart, saying “Daddy no leave me…please” and falls apart for “half the morning.”
Emma can be very compassionate and gentle with her 2 year old adoptive sister. She lights up when she smiles and laughs, she tries to engage her in her pretend play. When she cries she tries to make her stop, telling her in a louder and louder voice “stop, no cry, no cry.”
Developmental Functioning ~ Emma’s adoptive parents also report that “when she is OK” she is very engaging, bright, responsive and curious. Emma presents with age appropriate language, motor and cognitive skills when she is not distressed, however when distressed she regresses, i.e. language becomes more primitive, returns to needing diapers.
Self Regulation Information:
Presentation: Presentation shifts often and quickly; child is strongly affected by environmental triggers, others’ emotions, and internal states. Child may at times appear well-put-together, and at other times reactive, withdrawn, or overwhelmed. Emotions and energy are unpredictable, and child may vacillate between hyper- and hypo-aroused states Distress is experienced as diffuse and overwhelming. Although the full range of emotion is experienced, there is difficulty differentiating among degrees (i.e., sadness versus despair; irritability vs. rage) Emotional states (and therefore sense of self) may be fragmented from each other: when experiencing an emotional state, the child has difficulty thinking past it; when out of the state, the child may deny or have difficulty accessing it
Primary skills deficits: Highly active “alarm system”; low threshold for perception of threat, and overestimation of danger Inability to modulate emotional experience, across types of feelings; rapid escalation and/or constriction
Function of labile adaptation: This adaptation occurs as a result of a heightened biological alarm system, which originally arose to protect the child from frequent/ongoing danger. In the present, a wide range of both external experiences and internal sensations may be experienced as threatening, and trigger this alarm system. In the absence of an organized strategy, arousal level swings through the full range of hypo- to hyper-arousal.
Case Vignette ~ Jamie
Demographic Information ~ Jamie is an 8 year old Caucasian male who is currently living with his biological mother and his 11 year old biological brother. He is currently in the 3rd grade in a public school setting and is receiving special education services.
Presenting Concerns ~ Jamie presents as very emotionally reactive and clingy. He alternately clings to his mother and experiences rage toward her which manifests in tantrums and/or explosive behavior. He has a volatile relationship with his sibling and can become physically aggressive at times. Jamie does not follow rules at home and has very poor performance at school due to a high level of disorganization. In addition Jamie struggles with activities of daily living related to hygiene. Jamie’s mother is struggling with multiple stressors including finances, housing and his own mental health issues. He is seeking support around parenting strategies for both of his children.
Developmental History ~ Jamie was born to his biological mother and father in the US. According to Jamie’s mothers, his father was violent and controlling to his throughout their time together. When Jamie was a baby his mother left the marriage and took physical custody of the children. Jamie was identified at an early age as being developmentally delayed with significant delays in his motor development due to low tone. The children did have visitation with their father until Jamie reported ongoing sexual and emotional abuse by his father during visitation at age 5. Jamie’s brother was reportedly present for the abuse but did not make any allegations or disclose witnessing.
Current Presentation/Functioning Interpersonal and Social Emotional ~ Jamie is struggling in all areas of functioning. He needs significant support to complete activities of daily living and cannot independently was, brush his teeth, get dressed. He is struggling in school due to a high level of disorganization, poor attention and some low level behavioral non compliance.
Jamie exhibits disorganized attachment pattern with mother. He can be clingy at times and extremely dependent on both his mother and brother. At other times he is rageful and aggressive toward both of them. The sibling relationship is complicated by the abuse history. Jamie’s brother is much higher functioning in all domains of development.
Jamie primary relies on avoidance and constriction to manage intense emotions but can become aggressive when triggered- only in the home environment.
Jamie can be a very sweet little boy. He appears to really enjoy his school and the relationships that he has developed there. He has many interests and can articulate his interests very clearly.
Self Regulation Information:
Presentation: Access to the “power” emotions and cognitive states (i.e., anger, blame), but little ability to acknowledge or tolerate more vulnerable emotions (i.e., fear, sadness) Emotions and behaviors are connected to (and the result of) external events, and the child owns little responsibility for them (“If he hadn’t made me so mad I wouldn’t have hit him.”) Injustice is a powerful trigger Relationships with others may be marked by “oppositional behavior” (i.e., attempts to exert and test control); there is a profound sense of mistrust in relationship, and these children will “test” relationships, expecting rejection and/or abandonment
Primary skills deficits: Acknowledging and coping with vulnerable emotions Modulating intense emotion, particularly in the face of key triggers such as injustice and shame Modulating and managing behavior in the face of intense emotion Accepting responsibility for actions in social conflict Engaging empathy and perspective-taking in relationships
Function of externalizing adaptation: A common presentation among children like Jamie with a badly damaged sense of self, this adaptation allows children to protect themselves from overwhelming, distressing emotion; because skills to cope with intense affect are limited, there is no tolerance for thoughts or feelings that threaten their fragile sense of self