Kevin Creeden, M.A., LMHC Whitney Academy East Freetown, MA kcreeden@whitneyacademy

1. Re-Attaching the Brain:A Developmental Treatment ApproachforTreating Sexual Behavior Problems in Children and Adolescents KevinCreeden, M.A., LMHC Whitney Academy East Freetown, MA kcreeden@whitneyacademy .org

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

21. Maslow’s Hierarchy of Needs

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

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

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

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

26. Sensory Areas • Proprioception • Vestibular • Auditory • Visual • Tactile • Olfactory • Gustatory

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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