Check Yourself

1. Check Yourself Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

2. Great match (Very effective) Totally comfortable +10 +5 Terrible match (Not at all effective) 0 Really uncomfortable -5 Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

3. Attunement Is the Foundation for Supporting Youth Regulation Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

4. Observe Modulate Do ………and repeat Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

5. Attunement skills support youth regulation • OBSERVE: Yourself (caregiver): notice your own cues of distress, support needs, or loss of control • MODULATE:Yourself: If you can only stay in control of one thing, make it you. Use your in-the-pocket strategies of other resources. • OBSERVE: Your child: pick up on those “clues” of need / distress as early as possible. Increasingly, try to anticipate (get in front of) these by observing and anticipating patterns. Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

6. Attunement skills support youth regulation • (CO-)MODULATE: Your child: mirror what you see (simply), and cue, support, and reinforce use of regulation strategies. Pay attention to opportunities for control. • DO: After everyone is calm: reflect, process, limit-set, problem-solve. Don’t waste the “do” on the limbic system (yours or the child’s). Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

7. Opportunities to Build Pleasure in Engagement • Across levels of intervention (primary caregivers, staff, systems), pay attention to opportunities for positive engagement and interaction • Support caregiver-child dyads / family systems / other adult caregivers in building positive interaction into their routines; explore factors interfering with this • Notice / observe moments of shared pleasure • Integrate dyadic activity into session Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

8. The emotional brain is central to learning! • Human beings learn better if they have an emotional connection to their teacher! (Curran 2008)

9. Understand the human in front of you and you will improve their self esteem • If you do this you will improve their self confidence. • And if you do that , they will feel emotionally engaged with what you are doing. (Curran 2008)

10. The experienced of being attuned to is that the other person understands you deeply, that they ‘get’ you

11. Attunement: Angela and Sophie • Angela began to turn on her curiosity, to “hellicopter out” and recorded the circumstances that preceded violent episodes, bringing this information in to sessions. • Worker attuned to Angela and acknowledged how difficult it was being with Sophie. • Angela worked at reflecting rather than trying to “reason with”

12. Consistent Response Behavioral Response • The Main Idea: Support the caregiving system, whether familial or programmatic, in building predictable, safe, and appropriate responses to children’s behaviors, in a manner that acknowledges and is sensitive to the role of past experiences in current behaviors. Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

13. One approach to addressing challenging behavior… Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

14. Safe Attachment as the Context for Behavioral Response • Challenges with behavioral response may stem from: • Caregiver’s own (perhaps understandable) difficulty managing affect in the face of child behaviors • Caregiver’s difficulty understanding child behavior and appropriately responding • Lack of awareness / knowledge of appropriate skills Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

15. Consistent Response: Key Concepts An important part of building a safe environment is building predictability in both caregiver and systemic response Traumatized children’s lives are often marked by chaos. In an effort to re-gain (or gain) some safety, these children may attempt to control their environment and others around them.

16. There are (at least) two in the equation: • Youth responses to limits / behavioral guidelines may be affected by: • Heightened arousal and difficulty responding to in-the-moment cues • Prioritization of needs (i.e., survival need trumps cooperation) • Different sense of social justice Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

17. Support Behavioral Response With This Sequence • 1. Be Proactive • 2. Identify the need(s) • 3. Use your “go-to’s” • Meet needs • Support regulation and address safety • 4. Identify your other strategies purposefully • Praise and reinforcement • Problem-solving • Appropriate limits Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

18. Be Proactive • Trauma-impacted youth are complex: • Many different challenging behaviors • Many different states • Changing response in relationships • The most effective strategies are those that are proactive, or get in front of the behaviors • Identify a limited number (no more than 3) of behaviors to focus on • Pay attention to behaviors you want to see more of, not just ones you want to reduce Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

19. Identify the needs • Use your detective skills: remember to read the clues that tell you what your child’s needs, feelings, and experience might be. • Remember – what are the primary functions of youth trauma-based behaviors? • Survival (fight, flight, freeze, submit) • Need fulfillment (emotional, relational, physiological) Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

20. Use Your “Go-To’s” • Meet Needs • Once laid down by trauma, needs are experienced on a deep level and may need to be met many times, in many ways, for the need to decrease • Meeting needs does not mean you can not address behaviors in other ways, and does not reinforce the negative behaviors: it gets in front of them, and ideally will reduce the behaviors from occurring • Once you identify child needs, experiment with ways to meet them Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

21. Use Your “Go-To’s” • Support Regulation • Sometimes, the first clue that a need is not being met is dysregulation – a signal that the child’s brain has begun to shift into “survival mode” • At this point, the primary goal is to support regulation, and shift the child (and the caregiver, if necessary!) out of survival mode and into a more regulated state (off of the express road and back to the main road) • A “regulation break” may be enough to shift negative behaviors before they have a chance to start Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

22. Target Strategies Purposefully • Consider what strategies are in your behavioral toolbox, and use them purposefully according to the moment (child state, adult state, situational context, historical experience). • Make a plan – mentally walk through a “typical” scenario, and consider which strategies might work when • Consider strategies to be “experiments”; no one strategy will work for all children all the time • Multiple strategies can be used to address the same behavioral goal, at different times • Don’t try to change everything at once Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

23. Engage Youth in the Process • Actively engage youth in setting / defining / understanding household / milieu / contextual rules, as appropriate • Explore values underlying rules, and find common ground • Solicit youth input on ways adults can support them in following established structures; anticipate / collaborate on building success Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

24. Case example: Olivia Drawn from ARC Reflections Curriculum (Blaustein & Kinniburgh, with the support of the Annie E. Casey Foundation) Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

25. Olivia • Olivia, age 7, has continued to steal small items and hoard food in her new foster home. • She can be affectionate to her foster parents, but gets overwhelmed, clingy, and demanding when asked to do small tasks around the home. At times, her anger increases to the point that she throws things at her foster mother. • She appears to be settling into her new bedtime routine, but has a hard time separating when it’s time for lights out and can escalate which ends with a lengthy tantrum.

26. What might Olivia’s needs be? • (1) Hoarding; • (2) Bedtime separation; and • (3) Throwing objects.

27. What might Olivia’s needs be? • (1) Hoarding  Need fulfillment? Fear of having enough to eat? Survival strategy • (2) Bedtime separation;  Relational reassurance. Fear of nighttime? Fear of being alone? Fear of foster parents not being there when she wakes up? Difficulty transitioning? • (3) Throwing objects  Arousal response – survival. Engaging attention? Engaging task help? Getting space?

28. Use your “Go-To’s”: Meet Needs • Olivia’s foster parents were concerned about the food hoarding because her room seemed unsanitary – every time her foster mother cleaned, she found old, uneaten, and often rotten food stuffed in drawers and behind the bed. Establishing consequences for this behavior wasn’t effective. • With the support of Olivia’s therapist, her foster parents identified an easily accessible drawer in the kitchen and filled it with healthy snacks. They made this “Olivia’s drawer”, and let her know that no one would take food from there except for her. They checked in regularly to make sure she had enough, and otherwise, stopped talking about this issue entirely. • They also put a food-safe garbage can in her room, and encouraged her to put any food-related products in there.

29. Use your “Go-To’s”: Meet Needs The biggest power struggle that Olivia’s foster parents had was around Olivia’s completion of simple chores and self-care strategies. When she escalated to the point of throwing objects, the parents often escalated themselves. Olivia’s therapist guessed that the throwing might actually be a request for support, rather than a distancing strategy. As an experiment, Olivia’s foster mother began to do simple chores with Olivia. For instance, she would say, “Olivia, let’s pick up these toys. Which ones should we pick up first?” When she engaged with Olivia, she found the opposition decreased dramatically and Olivia was able to actively participate. Olivia was actually able to complete many tasks independently when her foster mother remained in the room and available.

30. Olivia Behavior: Throwing things at foster mother when overwhelmed completing tasks Problem solving: Olivia’s foster mother sat down with Olivia when she was calm, during their evening “chat time”. They talked about how everyone in the home was an important member of the family, and made contributions to keep the house running smoothly. Foster mother named and noticed that chores were hard for Olivia, and asked if they could figure out a way to help Olivia feel more successful at it. When Olivia had a hard time generating ideas, foster mother suggested that she and Olivia try to do some chores together to practice. She also talked about ways Olivia could let her know she was feeling overwhelmed.

31. Olivia Behavior: Throwing things at foster mother when overwhelmed completing tasks Praise and Reinforcement: Olivia’s foster parents worked hard to notice any time Olivia did something around the house (cleaning up her toys, putting clothes in the laundry, age-appropriate self-care like brushing teeth) and made a point of commenting on it. They also began to tune in to and name moments when Olivia got upset but didn’t become aggressive, and praised her for using her regulation tools.

32. Olivia Behavior: Throwing things at foster mother when overwhelmed completing tasks Limit-Setting: When Olivia escalated to the point of throwing and hitting, whoever was with her immediately stopped the activity and tried to mirror affect or energy (“I see you are upset.” “Your energy just got really big.”) and cue Olivia to take a break. If this did not work, her foster parent would carry her to the “regulation corner” (a special corner set up with blankets, pillows, and comfort objects) and either sit with Olivia in his or her lap or wrap her up in a blanket. They remained in the corner until it was clear that Olivia was calmer. Once calm, they talked about what happened, reminded Olivia that it was ok to be angry but not to throw, and put any thrown toys in “toy time out” for 10 minutes.

33. Olivia Behavior: Throwing things at foster mother when overwhelmed completing tasks Problem-Solving: Whenever an incident happened, Olivia’s foster parents would sit down with her during evening “chat time” and talk through the incident, their observations of Olivia’s behaviors and feelings, and think about ways to handle things differently the next time. Over time, they were able to identify “early warning clues” that Olivia was having a hard time, and use a special silly code phrase (“purple spotted dinosaurs”) that cued Olivia to use her regulation corner. They also made predictable “chore times” by building them into daily routine. Praise: Whenever Olivia went to her corner when cued, used coping skills, or completed chores successfully, her foster parents gave her a high five or verbal praise.

34. Some additional thoughts about consistent response • 1. Use of praise and reinforcement • 2. Praise and trauma response • 3. Some thoughts on Ignoring and Time Out

35. 1. Use of Praise and Reinforcement Praise and reinforcement: help build desirable behaviours as well as a sense of efficacy and self-esteem Don’t praise everything Start small Choose behaviours that are salient and desired Re-define success Go beyond “being good” Use concrete reinforcers and incentive systems to build positive behaviours

36. 2.Praise and the Trauma Response Praise may be ego-dystonic: when praise does not match a child’s self-perception it feels scary. (like a trick…”I am bad but you tell me I am good”) Positive statements (and positive relationships) may trigger attachment fears. (“Why attach when someone could take this all away tomorrow?”)

37. 3. The use of ignoring….. • “Ignoring is actively not attending to undesirable behaviours that are not immediately dangerous”

38. 4. Using Time Out with Traumatised Children • “Time out” is a particular type of limit setting that involves the removal of the child from a physical location (and the attention of others within that location) to a space where the child can spend a specified amount of time alone. ( Sitting in specified place..or sending to room)

39. Dan Hughes Shame versus Guilt

40. And for Angela and Sophie • Angela recognised that when she shouted at Sophie and sent her to her room, it was triggering her “shame”, instead she began looking for ways in which Sophie could do things with her as reparation, ie helping with tasks. • Angela occasionally took her own time out and demonstrated her own regulation skills.

41. Check Yourself Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

42. Great match (Very effective) Totally comfortable +10 +5 Terrible match (Not at all effective) 0 Really uncomfortable -5 Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

43. Attunement Consistent Response Caregiver Affect Mgmt. Applying Attachment in Service of TEI Routines Attachment Psychoed Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

44. FLUID PHASIC APPLICATION OF SKILLS In the Moment Goal Intervention Emphasis Caregiver Core Goals Child Core Goals Surviving and Tolerating Present-focused distress tolerance Recognize and support coping with current perceived experience Support caregivers’ tolerance of their own experience as well as youth experience, and engage in strengths Recognizing and Addressing Build a caregiving system that accurately sees and understands youth experience Self / Other Attunement Recognize and build understanding of patterns; understanding triggers and behavioral functions Shifting and transforming Meaning Making and Future Orientation Identify and explore past experiences, expand on self in the present, and engage links to the future Support caregiver’s own meaning-making and expand family identity Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

45. FLUID PHASIC APPLICATION OF SKILLS In the Moment Goal Intervention Emphasis Examples – application of caregiver goals Surviving and Tolerating Present-focused distress tolerance Support caregivers’ tolerance of their own experience as well as youth experience, and engage in strengths -Caregiver affect mgmtfocused on distress tolerance, awareness of own push-buttons -Family routines & rituals to support system stability -Parallel attunement to caregiver -Attunement focused on understanding child safety / need-seeking behavior -Effective in-the-moment response (consistent response, supported modulation) to enhance child and family functioning Recognizing and Addressing Build a caregiving system that accurately sees and understands youth experience Self / Other Attunement Shifting and transforming Meaning Making and Future Orientation -Established ongoing baseline rhythms that allow regulated family functioning on most days -Family identity and narrative; -Active family engagement in anticipating future (executive functions) Support caregiver’s own meaning-making and expand family identity Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

46. REGULATION Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

48. Regulation Overarching goal: Support youth ability to safely and effectively (at age- and stage-appropriate levels) 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 & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

49. Target skill-building to child needs • Challenges in “self-regulation” may present in multiple ways; in what ways is the child or adolescent currently attempting to modulate? • Many distressing behaviors represent the child/adolescent’s attempt to cope; work to understand the function behind the behavior, and support alternative strategies Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

50. +10 +9 +8 +7 +6 +5 +4 +3 +2 +1 0 -1 The POWER zone – living in hyperarousal THE ROLLER-COASTER – Comfort zone? What comfort zone? The KEEP-IT-COOL zone – any arousal is scary Individual Differences:The Comfort Zone Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005