In-Home Brief Therapy for Families with Troubled Youth August 10, 2012

1. In-Home Brief Therapy for Families with Troubled YouthAugust 10, 2012 Patricia Mares, M.Ed., PC, LSW patricia.mares@buckeyeranch.org / 614-205-1564

2. How I know what I know • Degree in psychology with an emphasis in child psychology • Master’s in Counselor Education • Training in SFBT • 10 years experience at TBR • Learning from fantastic foster parents • Research study through Ohio University

3. Reactive Attachment Disorder (RAD) • Characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts • Arises from failure to form normal attachments to primary caregivers in early childhood resulting from… • severe early experiences of neglect, abuse, abrupt separation from caregivers between ages 6 mos. & 3 yrs. • frequent change of caregivers • lack of caregiver response to child's communicative efforts • Example: Infants & toddlers growing up in orphanages in Eastern Europe in very deprived conditions

4. RAD (con’t) • Two forms • “Inhibited”: persistent failure to initiate or respond most social interactions in developmentally appropriate way • Extreme reluctance to initiate or accept comfort and affection, even from familiar adults, especially when distressed • “Disinhibited”: indiscriminate sociability, such as excessive familiarity with relative strangers • Indiscriminate and excessive attempts to receive comfort and affection from any available adult or peer, even relative strangers • Grossly disturbed internal working models of relationships often leading to interpersonal and behavioral difficulties in later life

5. RAD (con’t) • Diagnostic criteria: • Markedly disturbed and developmentally inappropriate social relatedness in most contexts; • Disturbance not accounted for solely by developmental delay and does not meet the criteria for pervasive developmental disorder • Onset before five years of age • History of significant neglect • Lack of identifiable, preferred attachment figure • Source: Wikipedia • http://en.wikipedia.org/wiki/Reactive_attachment_disorder

6. Behaviors • Overly cute, charms others to get them to do what he/she wants. • Trouble making eye contact when adults want him/her to. • Overly friendly with strangers. • Pushes caregiver away or becomes stiff when tries to hug him/her. • Argues for long periods of time, often about ridiculous things. • Tremendous need to have control over everything. • Acts amazingly innocent when caught doing something wrong. • Does very dangerous things, ignoring danger. • Deliberately breaks or ruins things. • Lacks conscience for his/her actions. • Teases, hurts, or is cruel to other children. • Unable to stop him/herself from doing things impulsively. • Steals • Demands things, instead of asking for them.

7. Behaviors (con’t) • Doesn't learn from his/her mistakes and misbehavior. • Tries to get sympathy from others by claiming abuse/neglect. • “Shakes off" pain when he/she is hurt, refusing to accept comfort. • Sneaks things without permission. • Pathological liar • Very bossy with other children and adults. • Hoards or sneaks food • Can't keep friends for more than a week. • Throws temper tantrums lasting two hours or longer. • Chatters non-stop, asks repeated questions, mutters, etc. • Accident-prone, or complains about every little ache and pain. • Teases, hurts, or is cruel to animals. • Doesn't do as well in school as could with even a little more effort. • Sets fires, or is preoccupied with fire. • Prefers to watch violent cartoons and/or tv shows or horror movies.

8. Solution Focused Brief Therapy • Developed by Insoo Kim Berg and Steve de Shazer • Client as expert • Average therapy duration of 3 sessions • Key elements • Problem description • Miracle question • Exception question • Scaling question • Compliments • What’s better question • Coping question (crisis intervention)

9. Future rewarding for positive behavior Office setting Relationship between therapist and client Therapist as expert Ongoing time frame Focuses on thinking leading to behaviors Reality not objective but defined by client Office, school, home Relationship between client and others Client knows best Brief time frame Focuses on strengths and possibilities CBT vs. SFBT

10. CONTROL SFBT CBT Multi-modality treatment approach

11. CONTROL • Control: Adult must maintain it in order to gain trust • Options: Youth provided with 2-3 options/alternatives acceptable to the caregiver • Neutrality: Caregiver uses neutral words and tone in response to “acting-out” behavior to demonstrate continued control over youth and situation • Trust: Caregiver regularly provides youth with basic needs and psychological needs to cultivate feeling of trust and security • Repetition: Caregiver repeats 3 times in simple language and neutral tone the natural consequence if “acting-out” behavior continues • Others: Influential adults involved in youth’s life educated about issues and importance of interacting with youth in a specific way • Love: Caregiver shows empathy and care through use of customary hugs etc. ordinarily provided by parents; youth taught to understand difference between love and pity, and most importantly, to love themselves

12. Case examples

13. CT • 10 year old boy with history of instability • Foster mom began to use neutrality, then demonstrations of love • Initial increase of negative behaviors when child realized he was not in control • Beginning of stabilizing emotions • Interference of custodial agency

14. CB • 16 year old boy conceived in a one night stand; friction between parents • History of being in therapeutic camps in Utah and boarding school in New York • Assault charges • Decision to transition to birth father and use integrative services/mediation • Successful reunification and graduation/entering military

15. JD • Boy in foster care from ages 7 to 9 with RAD diagnosis • Constant rages and inability to control mood • Control work begun with foster mom • Custodial agency made aftercare with research project part of adoption process • Adoptive parents very receptive and having good success so far with child’s behaviors

16. RF • 9 year old boy with history of multiple moves between relative and foster placements • RAD diagnosis and difficulty with rages and mood management; past abuse by birth mom • Difficulties in the school system • Custodial agency asked for after care services • Met with birth mom several times and staff of new school and reunification has lasted a year

17. JA • 14 year old boy with RAD and FAS diagnoses referred by local counselor • Met multiple times with adoptive family with child and child alone • Youth had multiple issues and trouble with raging and stealing • Parents frustrated and not able to maintain neutrality or follow up on suggestions • Residential placement

18. ED • 12 year old adopted boy from China • Already been through traditional attachment therapy • Parents frustrated with hoarding and constant annoying behaviors • 2 in home appts. and follow up phone calls and facebook messaging • Decrease in negative behaviors

19. NT • 13 year old boy living with paternal grandmother and step-grandfather • 6 year history of instability with birth parents • Youth has absolutely no trust in adults and grandparents arguing best practice with each other • Youth reporting no interest in anything • Custodial agency requesting inclusion in project and follow up aftercare with family.

20. MC • 5 yr old girl living with maternal grandmother • Child estranged with mother because of AOD issues and sister being favored by mother • Ongoing issues of rage, including attempts to hurt self with butcher knife • First child enrolled in study and met with grandmother, child and extended family • With crisis support, child more successful

21. Easier said than done Some more coachable than others Limited control over others Deep seated feelings of unworth difficult to get past Unknown effectiveness Empowers caregivers Can be carried out by anyone (simple and inexpensive) Engages everyone in child’s life Opportunity to demonstrate love By explaining behaviors, frustration can be lowered Challenges and opportunities

22. Resources • Websites • controlrad.com • attachment.org • sfbta.org • Books • When Love is Not Enough (2005) by Nancy Thomas • 99 Ways to Drive your Child Sane (1999 by Brita St. Clair