Attachment Focused Interventions:

1. Attachment Focused Interventions: A Workshop for Parents and Professionals

2. Part I Complex Trauma Developmental Trauma Disorder

3. Complex Trauma(Cook, Blaustein, Spinazzola and van der Kolk, 2003)http://www.nctsnet.org/sites/default/files/assets/pdfs/ComplexTrauma_All.pdf Definition Children’s experience of multiple traumatic events that occur within the care giving system • Prenatal exposure to drugs/alcohol • Neglect/Institutionalization • Abuse • Abandonment/Multiple Moves • Pain/Illness/Hospitalization Involves simultaneous or sequential occurrences of child maltreatment—that are chronic and begin in early childhood

4. Complex Trauma Areas of Impairment • Attachment • AffectRegulation • Dissociation • Cognition • Biology • BehavioralControl • SelfConcept

5. ATTACHMENT Attachment is the process by which an emotional connection develops between an infant and his/her caretaker This process organizes the infant physiologically and psychologically Attachment becomes the basis for how he/she will relate to the world, learn and form relationships In addition to the basic needs such as food, shelter and clothing, the infant needs emotional care which is essential for his/her development Attachment grows through daily interactions between caretaker and infant Smiles, nurturing touch, eye contact, mutual play build trust and security in the child This first relationship becomes the blueprint for all future relationships It is also the origin of conscience development, empathy, self-esteem and cause and effect thinking Insecure attachment patterns seen in 80% of maltreated children 5

6. NEED ANGER HIGH AROUSAL RAGE TRUST GRATIFICATION 6

7. DISSOCIATION AFFECT REGULATION Difficulty with emotional self-regulation Difficulty describing feelings and internal experience Problems knowing and describing internal states Difficulty communicating wishes and desires Predisposed to earlier onset of affective problems, which is associated with more episodes and poorer outcome • Distinct alterations in states of consciousness • Two or more distinct states of consciousness • Hyperarousal & Dissociative • Begins as a protective defense mechanism and then is utilized more frequently as trauma continues

8. Think Deer….

9. Cognitive Problems with… • Irrational cognitions • Sustained curiosity/initiative • Processing new information • Focusing and completing new tasks (hypervigilence vs. hyperactivity) • Understanding own contribution to what happens to them (cause-and-effect thinking) • Object constancy • Orientation with time and space • Learning disabilities • Abstract thinking

10. Biology Problems with… • Experiences impact brain development • Lifelong reactivity to stress • Problems with coordination, balance, body tone • Somatization • Analgesia (inability to feel pain) • Hypersensitivity to physical touch • Wide variety of medical problems: pelvic pain, asthma, skin problems, autoimmune disorders • Sensory Integration Dysfunction

11. Behavioral Control • Poor impulse control • Self destructive behavior • Aggression • Self soothing behaviors • Sleep and eating disturbances • Substance abuse • Excessive compliance or oppositional behavior • Reenactment of traumatic past

12. Self Concept • Lack of coherent sense of self • Disturbance of body image • Low self-esteem • Poor sense of separateness

13. 7 Core IssuesThe Adoption Overlay Loss Grief Self-concept Identity Shame and Guilt Intimacy and Relationships Control

14. Research Vineland Adaptive Behavioral Scales

15. Research The Vineland Measures Development… Socialization Domain • Interpersonal Relationships • Play and Leisure Time • Coping Skills Motor Skills Domain • Gross • Fine • Behavior • Internalizing • Externalizing Communication Domain • Receptive • Expressive • Written Daily Living Skills Domain • Personal • Domestic • Community

16. Chronological Age 4 years, 4 months 5 years, 7 months Communication • Receptive 1 year, 3 months 1 year, 6 months • Expressive 2 years, 6 months 3 years, 5 months • Written 4 years, 5 months 4 years, 11 months Daily Living Skills • Personal 3 years, 1 month 5 years, 0 months • Domestic 4 years, 6 months 5 years, 6 months • Community 3 years, 1 month 4 years, 5 months Socialization • Interpersonal Relationships 1 year, 1 month 2 years, 0 months • Play and Leisure Time 0 years, 4 months 0 years, 8 months • Coping Skills 1 year, 10 months 3 years, 4 months Motor Skills Domain • Gross 2 years, 1 month 4 years, 11 months • Fine 3 years, 6 months 4 years, 7 months Behavior • Internalizing Clinically Significant Clinically Significant • Externalizing Elevated Elevated

17. Chronological Age 6 y, 0m 7 y, 0 m 8y, 3m Communication • Receptive 1 y, 6 m 1 y, 11 m 2y, 2m • Expressive 3 y, 2 m 5 y, 0 m 4y, 6 m • Written 5 y, 2 m 6 y, 9 m 7y, 9 m Daily Living Skills • Personal 4 y, 7 m 6 y, 1 m 6y, 6m • Domestic 4 y, 4 m 3 y, 11 m 7y, 7m • Community 3 y, 7 m 5 y, 5 m 5y, 5m Socialization • Interpersonal Relationships 0 y, 3 m 2 y, 3 m 2y, 5 m • Play and Leisure Time 0 y, 9 m 2 y, 10 m 2y, 10m • Coping Skills 1 y, 6 m 2 y, 3 m 2y, 2m Motor Skills Domain • Gross 4 y, 5 m 5 y, 11 m 6y, 10m • Fine 6 y, 6 m 6 y, 6 m 6y, 10m Behavior • Internalizing CS CS CS • Externalizing CS CS CS

18. Chronological Age 7 years, 11 months 9 years, 1 months Communication • Receptive 1 year, 11 months 2 years, 11 months • Expressive 6 years, 4 months 6 years, 7 months • Written 9 years, 0 months 10 years, 8 months Daily Living Skills • Personal 6 years, 1 month 6 years, 6 months • Domestic 5 years, 5 months 9 years, 6 months • Community 7 years, 6 months 8 years, 7 months Socialization • Interpersonal Relationships 1 year, 1 month 1 years, 9 months • Play and Leisure Time 2 years, 9 months 5 years, 3 months • Coping Skills 1 year, 6 months 3 years, 5 months Motor Skills Domain • Gross Age Equivalent Age Equivalent • Fine 4 years,11 months 6 years, 10 months Behavior • Internalizing Clinically Significant Elevated • Externalizing Clinically Significant Elevated

19. Chronological Age 11 years, 1 months 12 years, 5 months Communication • Receptive 1 year, 9 months 3 years, 11 months • Expressive 5 years, 11 months 7 years, 7 months • Written 9 years, 2 months 10 years, 10 months Daily Living Skills • Personal 5 years, 11 month 11 years, 3 months • Domestic 7 years, 7 months 9 years, 6 months • Community 8 years, 11 months 9 years, 6 months Socialization • Interpersonal Relationships 0 year, 11 month 3 years, 7 months • Play and Leisure Time 3 years, 2 months 9 years, 3 months • Coping Skills 2 year, 3 months 5 years, 6 months Motor Skills Domain • Gross Age Equivalent Age Equivalent • Fine Age Equivalent Age Equivalent Behavior • Internalizing Clinically Significant Elevated • Externalizing Clinically Significant Elevated

20. Part II – Helping the Traumatized Child Translating Theory into Practice: A Tool-Box of Techniques

21. Part II “Deerly” Treatment

22. Treatment Principles Parent-Centered and Child-Focused Develop a Coherent Narrative

23. Treatment Principles Facilitate Grief Shock/Denial Bargaining Depression/Sorrow Anger Resolution

24. Treatment Principles Encourage Emotional Regulation (Decrease Dissociation and Hyperarousal) Encourage Behavioral Change

25. Treatment Principles Facilitate Developmental Gains Attachment Affect Regulation Dissociation Cognitive Behavioral Control Self-concept Biology

26. Treatment Principles Nurture, humor and fun! Eye contact, Touch, Talking, Smells, Food, Motion, Warmth

27. A Tool-Box of Techniques The narrative is an emotionally rich story that makes sense of one’s life. • Affirms reality • Creates meaning, provides closure, reduces need to ruminate • Organizes memories—implicit and explicit— into one chronological account • Enhances cause-and-effect, and decreases anxiety, insecurity and confusion • Reduces disparity between what the child is feeling (fear) and current reality (safety: with parents and therapist) • Reduces isolation, feeling of being unknowable and different • Creates the ability to alter the child’s dysfunctional patterns of interaction • Facilitates grief which leads to developmental growth

28. A Tool-Box of Techniques Explicit or Declarative Memory • We have a conscious ability to retrieve the memory and state the facts and events. • We can recall the event Implicit or Nondeclarative Memory • Implicit memory systems  store emotions, sensory experiences, and expectations and assumptions about relationships based on prior experiences • Implicit memories form early in life prior to the individual having language • They cannot be recalled but they can be triggered Briere , John and Catherine Scott (2006.) Principles of Trauma Therapy: A Guide to Symptoms, Evaluation and Treatment, Thousand Oaks: Sage Publications.

29. A Tool-Box of TechniquesTelling the narrative “story”… • Start at the beginning • Cases of Limited information • Verbal and concrete methods • Pace- maintain emotional regulation • Value free – the child decides who to love • Use adoption language: birth mom, birth dad, etc. • Adjust language according to child’s age: chronological and developmental • Repeat, repeat, repeat!

30. A Tool-Box of TechniquesTelling the narrative “story”… • Anticipate questions… • Say “I don’t know” as needed • “Why did my birth parents use drugs?” • “Do you think my birth mom thinks about me?” • “Do you think she is in jail?” • “Does she have any more children?” • “If they get better, can I go live with them again?” • “Why didn’t anyone in my country want me?” • “Why didn’t the orphanage ladies take me home?” • “Do you think my orphanage friends got adopted?” • “Are my birth parents alive?” • “Are my siblings safe?” • “Do you think my siblings think about me?” • “Why did you pick me?” • “What would you have done if I had been your baby?”

31. The Life Book A BOOK THAT RECORDS A CHILD’S HISTORY FROM THE BIRTH PARENTS TO THE PRESENT A Tool-Box of Techniques The Timeline

32. A Tool-Box of Techniques Children’s Books Journaling Art Role-plays Photos Videos

33. Improved flexibility, strength, balance, muscle tone Increases the individual’s awareness of their breathing, and then teaches way to regulate breathing. This is important for calming down. Pizer, Ann. Benefits of Yoga. [online]. http://yoga.about.com/od/beginningyoga/a/benefits.htm A Tool-Box of TechniquesYOGA • Taming the Monkey Mind • This is the mind that jumps from thought to thought like a monkey jumps from tree to tree. • Emphasis is on being in the present moment. The mind gains the ability to focus and concentrate. • Stress relief via stretching. • Stress-related tension is stored in the body, making a person feel tight, and often causing pain.

34. Helps in relieving discomfort from gas, colic, and constipation Improves blood circulation aids in digestion Improves quality and amount of sleep Enhances development of the nervous system and Stimulates neurological development (brain function and brain development) Reduces aggression (Cozolino) A Tool-Box of TechniquesInfant Massage • Increases alertness and heightened awareness • Reduces stress hormones • Improves immune function • Stimulates oxytocin, the “nurturing hormone” • Deepens bonding: • Stimulates growth and healthy development of body, mind and spirit • Relaxing and soothing International Association of Infant Massage. What are the Benefits of Infant Massage? http://www.iaim.ws/faqs.html

35. “Training for the Brain” A Tool-Box of TechniquesNeurofeedback

36. Part III – Helping the Family Parenting “Deerly”

37. Parents Need Nurture Too! Complex Trauma creates a Complex Family System • Most adoptive families are healthy prior to the arrival of a child with a history of complex trauma. • However, the family often appears unhealthy upon entering services. • The state of the family is a responseto the challenges involved in parenting a child with complex trauma issues.

38. Trauma, by definition… A single experience or an enduring or repeating event or events, which completely overwhelm the individual’s ability to cope—consumption and depletion of coping skills. There is frequently a violation of the person’s familiar ideas—expectations—about the world, and the person is put in a state of confusion and insecurity—cognitive dissonance. This is also seen when people or institutions depended on violate or betray the person in some unforeseen way—isolation. It usually involves a feeling of complete helplessness in the face of a real or subjective threat to one’s life or to that of a loved one’s life, integrity and sanity—losses. There is also an inability to integrate the emotions—grief and negative emotional climate—involved with the traumatic experience.

39. The Dynamics of the Complex Family System • Expectations • Cognitive Dissonance • The Consumption and Depletion of Coping Skills • The Emotional Roller-Coaster • Isolation • A Sea of Grief

40. The Dynamics of the Complex Family SystemExpectations • I want to help a child in need • I am unable to have children • I heard an ad on the radio • Love will be enough • I know what they have been through • My spouse or partner wants to adopt • I thought a child would strengthen our marriage • A relative’s child needs my help • I want my children to have more siblings • I want to adopt a young child • I don’t want to deal with birth parents • I didn’t expect to adopt (foster parents)

41. The Dynamics of the Complex Family SystemExpectations Typically-Developing Children “I expect to have a playmate”

42. The Dynamics of the Complex Family SystemExpectations The Adoptee • “I think you will abuse me.” • “I think I am moving somewhere else.” • “I think you are another orphanage.” • “I am unlovable.”

43. The Dynamics of the Complex Family SystemExpectations Expectations and reality collide

44. The Dynamics of the Complex Family System The Consumption and Depletion of Coping Skills “Nothing works!” “We’ve tried it all!”

45. The Dynamics of the Complex Family System Ineffective Coping Styles – Repeating the Patterns Trauma Reenactment or Compulsive Repetition Children who have experienced trauma alter the dynamics of the adoptive family in a manner that causes a repetition of their abandonment, abuse, neglect, deprivation or life with a drug addict. Their trauma is reenacted, albeit on a smaller scale, within the adoptive home. (van der Kolk, 1989)

46. and Effective Coping Styles Alter coping and attachment styles & Provide New Parenting Tools

47. Parenting Pearls…Control, Control, Control • What you want to control • What you need to control • What you can control • What you should not control • What you cannot control

48. Pick and choose carefully Avoid control battles Win the ones you take on 48

49. Parenting Pearls… • Developmental Parenting • “Developmental interruptions result in delays that leave the individual developmentally immature”

50. Developmental Delays Cause and Effect Thinking Problem-Solving Skills Moral Development Social Skills