Not in Isolation. The Importance of Relationships and Healing in Childhood Trauma. Michelle Taylor for the Creswick Foundation 2013

Transcription

1 Not in Isolation The Importance of Relationships and Healing in Childhood Trauma Michelle Taylor for the Creswick Foundation 2013 Creswick Fellowship Michelle L Taylor BA (Hons), MPsych MAPS NMT Consultant Berry Street Take Two Associate Berry Street Childhood Insititute

2 Table of Contents Acknowledgements Introduction Overview of Itinerary Observed Neurodevelopmentally Informed Interventions Reflections and Conclusions Dissemination Glossary References Appendix A Report for the Creswick Foundation Fellowship prepared by Michelle Taylor. 1

3 Acknowledgements The opportunity to travel to the United States and Canada and visit with ChildTrauma Academy Neurosequential Model of Therapeutics (NMT) Flagship Sites and Fellows so to further extend our knowledge in relation to neurodevelopmentally informed interventions would not have been possible was it not for the work and financial assistance of the Creswick Foundation and its trustees. Receiving a Creswick Foundation Fellowship is an absolute honour and privilege and it is my hope that the learning from this experience will contribute to ongoing work with our most vulnerable citizens: traumatised infants, children and adolescents. Thanks also to Marg Hamley, Berry Street s Childhood Institute Director and Annette Jackson, Director Take Two for their encouragement and support to undertake this venture. My deepest thanks goes to my husband Craig and my family for their patience and understanding as I left them at home in Australia for nine weeks to undertake this Creswick Fellowship. Craig your support and encouragement to do this, coupled with you keeping me focussed on the task at hand when I was homesick, provided me the safe base I needed at times when the exploration became a little too adventurous or the nights too long. This report and the learning from my Creswick Fellowship would have been impossible had it not been for the generosity, hospitality and professional commitment of Dr Rick Gaskill and the staff at Sumner Mental Health; Linda and Ralf Zimmerman, Kurt Wulfekhuler and the staff of The Sandhill Center; Mark Strother, Michelle Maikoetter, Jim Taylor and the staff of Cal Farley s Boy s Ranch; Dr Dawn O Malley, Joe Heritage and the staff of Alexander Youth Network; Sister Amy Wilcott, Kirk Ward and the staff of Mount Saint Vincent Homes; George Ghitan, Dr Emily Wang, Denise Zoellner-Manderson and the staff of Hull Services; Dr Kristie Brandt, John Brandt, the Napa County Therapeutic Preschool and Dr Bruce Perry. I am most thankful to Berry Street and Take Two for their support, encouragement and provision of study leave so to embark on this venture. My role as NMT Consultant with Berry Street s Take Two program afforded the opportunity to develop such a comprehensive understanding of neurodevelopment and the impact of trauma. With this knowledge I was able to conceive the idea of exploring the variety of neurodevelopmentally informed interventions being used by our colleagues overseas. Further, I wish to extend my gratitude to my colleagues in the Practice Development and Training team at Take Two who carried elements of my workload in my absence, particularly Sarah Waters and Clare Ryan, who regularly ed me and helped me feel connected to my world at home in an ongoing way. Finally I want to thank to the amazing children and young people I met as I travelled across the United States and Canada at each of the organisations I visited. These young people were so open and willing to share their experiences of the programs they were part of; the interventions they were receiving; their life stories and to spend time teaching me about their country and learning about Australia from me. Working with children and young people and having them invite me into their life, their history and their present is such a privilege and honour. This is never something I take lightly and is the most amazing and precious gift. The young people I met in the USA and Canada were no exception! Report for the Creswick Foundation Fellowship prepared by Michelle Taylor. 2

4 1. Introduction The assessment and treatment of children who have experienced trauma has undergone a major theoretical shift in the last five to ten years. Modern advances in neuroscience and neurodevelopment have provided an enhanced and enriched understanding of the impact of trauma and attachment disruption on the developing brain (Perry, 1994; Perry et al 1995; Perry & Pollard 1998; Perry 2001, 2006, 2008, 2009; Porges 2011; Schore 2002, 2005; Siegel & Bryson 2012). These theoretical advances suggest that trauma experienced during pregnancy, infancy and early childhood impacts the development and organisation of the brain. Specifically, this results in developmental disruption to various functions and behaviours for which the brain is responsible. Accordingly we have seen a corresponding shift in the way we think about and approach therapy with traumatised infants, children and adolescents. In Victoria Australia, Berry Street has been applying the concepts of neurodevelopment and trauma into its clinical practice in the Take Two program since it began in 2004 and more specifically through implementation of NMT since Take Two is a therapeutic service for children who are clients of Child Protection in Victoria Australia. NMT is an assessment model developed by Dr Bruce D Perry of the ChildTrauma Academy in Houston, Texas. NMT is not a specific therapeutic technique or intervention, rather it is a way to organise information about a child s history and current functioning to inform and guide the therapeutic process. NMT helps to plan treatment that is developmentally sensitive and promotes self-regulation by improving brain functioning. NMT has the following core neurodevelopmental concepts at its heart: Each part of the brain is responsible for mediating different functions. The brainstem at the lower part of our brain mediates functions such as heart rate, temperature regulation and blood pressure. The diencephalon mediates functions such as sleep/wake cycles, appetite/hunger and motor skills. Our limbic system can be thought of as the emotional and relational centre of the brain. Uniquely human and at the top of our brain is our cortex - the home of complex executive processes such as abstract thinking, problem solving and language skills. While each part of the brain is responsible for certain functions, they work together and can influence each other. The brain develops from the bottom up (brainstem to the cortex) and healthy organisation of one part is largely dependent on the lower part being organised well. Our brain develops as a function of our genetics and experience and organises in a use dependent way. The more we experience particular events, the stronger the neural connection made will be as a result. So if you grow up experiencing lots of stress and fear, you will grow up more sensitised to stress and fear. Most neural organisation happens in the first four to six years of life, however, the brain continues to develop throughout our lifespan. Early experiences are much more powerful in organising the way our neural connections are formed than later experiences. Different parts of the brain are more easily changed than others. For very good reasons the lower, less complex parts of our brain are harder to change than our cortex, which is much more plastic. The other key element to healthy brain organisation is the provision of safe, attuned, responsive, predictable and nurturing relationships. (Perry 2006) With these concepts in mind, infants and children who experience trauma and/or neglect in consistent or chaotic ways during the period of rapid brain growth and organisation often have lasting neurodevelopmental insults as a result. Especially if they do not have access to well tailored therapeutic approaches for recovery and healing. While they will display the behavioural challenges that we so readily see, many of these children will also have difficulties in functions mediated by lower parts of the brain, such as faster resting heart rates, motor and/or sensory difficulties, attention problems, and sleep difficulties. The foundations for and capacity to effectively use the cortical processes is compromised if the lower parts of the brain are disorganised and dysregulated (Perry 2001, 2006; Siegel & Bryson, 2012). Often we see that these clients are unable to benefit initially, from traditional talking therapies because they are fundamentally too dysregulated to be able to attend, reflect and think clearly. To be more neurodevelopmentally informed in trauma treatment and effective in healing, it makes sense that we need to reorganise and regulate the lower parts of the brain before we tackle the higher and more cognitive parts of Report for the Creswick Foundation Fellowship prepared by Michelle Taylor. 3

5 the brain. Thus we need to sequentially reorganise and regulate the brains of these children so to assist them to be ready to benefit from traditional treatments. Principles from neuroscience and neurodevelopment suggest that activities to promote and develop sensory integration and self-regulation form the foundations of trauma treatment. The NMT assessment process identifies strengths and weaknesses of functioning for the individual, and by inference brain functioning, and informs a therapy plan that aims to assist in developing and/or reorganising the brain in a developmentally appropriate way. In addition to its focus on brain functioning, the NMT also considers adverse experiences such as exposure to family violence and parental substance over the child s lifetime as well as opportunities the child may have had to develop and engage in healthy, supportive, nurturing relationships. The NMT report provides a profile of the child s developmental risk over time as well as their current relational health, which then informs the child s treatment plan. Treatment plans are developed to enhance emotional regulation skills by improving brain functioning using patterned repetitive movement/activities, the provision of relationally rich environments to manage the child s stress response system, and encourages psycho-education and inclusion of parents and teachers to improve the child s chances for success. The Creswick Foundation Fellowship afforded me the opportunity to travel to the United States of America and Canada between May and June in 2014 to visit five of the seven ChildTrauma Academy Flagship sites (Berry Street Take Two is one and a seventh was announced just after I finalised my Fellowship submission) and two of the ChildTrauma Academy Fellows. This allowed me to observe and explore the application of the NMT informed interventions such as sensory and self-regulatory activities and the impact these interventions have had in addressing and supporting trauma recovery for infants, children and adolescents. The five ChildTrauma Academy Flagship sites that I visited were largely applying the NMT assessment framework in their residential and onsite day treatment centres. I was able to develop an understanding of the types of activities being used by our ChildTrauma Academy partners, their frequency and scheduling in the lives of vulnerable children, that lead to improved self regulation and enhanced relational connections. Sumner Mental Health is a community based mental health service for infants through to the elderly and I visited with Dr Rick Gaskill ChildTrauma Academy Fellow, their child and adolscent mental health team and the therapeutic preschool they support in partnership with Futures Unlimited. The Child Services team are case managers who do both targeted case management (typical of Australia s mental health case management roles e.g. CAMHS) and therapeutic support case management, which incorporates a clinical intervention role. Sumner Mental Health support the preschool with the provision of Individual Psychosocial Rehabilitation (IPR) staff who provide one to one hourly support for the most difficult children so to scaffold challenging times in the preschool envioronment. The preschool services approximately 100 children, of which up to 15 were assessed and met seriously emotionally disturbed (SED) criteria for mental health therapeutic support in the form of direct therapeutic intervention service, case management and IPR at the preschool. Sandhill Center is a privately run residential program for children ages five to 13, who are experiencing significant difficulties functioning in their current home, school or community due to difficulties in regulating their emotional states. Sandhill has capacity for up to 30 children and adolescents at any given time and their average length of stay is around 18 months. Cal Farley s Boys Ranch is one of America s largest privately-funded child and family service providers specializing in both residential and community-based services at no cost to the families of children in their care. Cal Farley s hosts 28 residential homes each of which caters up to 12 children and young people. At capacity Cal Farley s can have up to 260 children and young people at a time with an independent schools district onsite. Again the average reported stay at Cal Farley s was approximately 18 months to two years. Alexander Youth Network (AYN) is a non profit community based organisation receiving funding from fee for services (medicaid, insurance and such) as well as contributions from individuals, corporations, foundations and government agencies. AYN serves children ages five to 18, who are referred from hospitals, physicians, parents, schools and from state and county organisations such as department of social services and juvenile justice. AYN serve over 7000 children each year. AYN provide an array of mental health treatment for serious emotional and behavioural difficulities including: diagnostic and outpatient services, community based programs, multisytemic day therapy, therapeutic foster care and an onsite, 36 bed psychiatric residential treatment facility (PRTF). Clients at AYN s PRTF have an average stay of six months, dependent on funding sources and managed care organisations. Mount Saint Vincent Home (MSV) is a treatment centre for children with severe behavioural and emotional challenges due to mental illness, trauma, abuse, or neglect. MSV s residential treatment program has three cottages for 36 girls Report for the Creswick Foundation Fellowship prepared by Michelle Taylor. 4

6 and boys ages five to 12. The day treatment program at Mount Saint Vincent serves children five to 13. All children enrolled in the day treatment program receive individual therapy, family therapy, and group therapy. MSV also offer in home treatment, a K-8 school with developmentally attuned classrooms and an early learning centre. The average length of stay for residential clients at MSV is seven to eight months and ten months for their day treatment clients. Hull Services provide 28 different programs in the Calgary community. My visit centred on the residential and educational programs: the Preadolescent Treatment Program and the William Roper Hull School. The Preadolescent Treatment Program provides 11 child protection beds and two fee for service beds for children aged six to 12yrs. The Preadolescent Treatment Program is a trauma informed attachment-based program, which provides a relationally rich environment, improves self-regulation, and reduces maladaptive behaviours. The average length of stay is one to one and a half years. The school services children providing K-12 education, 60% of students are from campus programs and 40% day treatment/off campus. Alberta Education has identified the children attending the school as having Severe Emotional/Behavioural Disabilities or Severe Physical or Medical Disabilities that impact on their functioning. There are 12 children per classroom that is staffed by one teacher and two counselors, whose role is to regulate the children. Dr Kristie Brandt is the Director, Parent-Infant & Child Institute; Assistant Clinical Professor of Pediatrics VF UC Davis Medical School; UMass Boston Infant-Parent Mental Health Postgraduate Program Co-Developer & Napa, CA Program Director and ChildTrauma Academy Fellow. I spent a weekend with Dr Brandt at her Infant-Parent Mental Health Fellowship in Napa whereby they were exploring the application of NMT in intervention planning for neurodevelopmental healing using Dr Brandt s Mobius model of care. As part of this visit, Dr Brandt took me to the Napa County Therapeutic Preschool. During my visit in Napa, I also had time to visit with Dr Perry. In between some of the agency site visits the Creswick Foundation Fellowship also afforded me the opportunity to attend the University of Denver Human Animal Connection, Transforming Trauma Research Developments and Methods for Trauma-Informed Animal-Assisted Interventions conference and the Inaugural NMT Symposium in Banff, where I had opportunity to present two papers: one outlining the implementation of NMT in Take Two and one overviewing the pilot Rhythm Project, an application of patterned, repetitive movement and music breaks in primary school classrooms (for more information see page 12). Report for the Creswick Foundation Fellowship prepared by Michelle Taylor. 5

7 2. Overview of Itinerary April 30 - Depart Melbourne May 4 th & 5th - Dr Rick Gaskill & Sumner Mental Health Services Wellington Kansas. May 7 & 8 - Transforming Trauma Research Developments and Methods for Trauma-Informed Animal- Assisted Interventions, Denver Colorado. May Sandhill Child Development Center, Los Lunas New Mexico. May Cal Farley's Boys Ranch, Amarillo Texas. May Alexander Youth Network, Charlotte North Carolina. June Mount Saint Vincent Home, Denver Colorado. June ChildTrauma Academy & Hull Services NMT Symposium, Banff Alberta. June Hull Services Calgary Alberta. June University of Massachusetts Boston Infant-Parent Mental Health Postgraduate Program, Napa California. June 30 - Dr Kristie Brandt, Napa California. June 30 Napa County Therapeutic Preschool July 3 - Arrive Melbourne Australia. Report for the Creswick Foundation Fellowship prepared by Michelle Taylor. 6

8 3. Observed Neurodevelopmentally Informed Interventions. It was interesting to be direct witness to the implications of the theoretical and practice shift in the child trauma treatment field at a time where it seems international government; insurance companies and mental health funding bodies are increasingly requesting services and practitioners to demonstrate the use of interventions with a strong evidence base. I suspect as we continue our research, theoretical evolutions and empirical investigation of models of practice, there is always likely to be a lag between what we are doing and the provision of a strong evidence based for its efficacy in clinical practice. Kazdin (2008) marks the distinction between evidence based treatment and evidence based practice stating Evidence based treatment refers to interventions or techniques to have produced therapeutic change in controlled trials, while evidence based practice refers to clinical practice that is informed by evidence about interventions, clinical expertise and patient needs, values and preferences and their integration in decision making about individual care (Kazdin, 2008). I appreciate that we are beginning to be faced with similar funding based challenges in Australia, specifically in the private sector, however this was quite confronting and a widespread issue and pressure for the public mental health and welfare agencies I visited in the United States and Canada. Managed care organisations and insurance companies place considerable pressure on these services to use and demonstrate clear outcomes from evidence based treatments and were quick to remove funding if they considered a child treatment resistant. While many of the organisations were facing the very real challenge of navigating health funding on the basis of evidence based treatment, I was overwhelmingly impressed by the consistency between agencies in their confident use of neurodevelopmentally based interventions as evidence based practice. Furthermore agencies are actively thinking ahead as to the capacity to contribute further to the evidence base around the interventions being used. With the enhanced knowledge being contributed by neuroscience and neurodevelopment and the bringing together of neuroscience, trauma and attachment theories we now have a strong theoretical framework to guide good clinical practice confidently. I observed a considerable consistency between agencies also in the types of neurodevelopmentally informed interventions being used see Table 1. While there were some innovative and new methods of intervention being applied and trialled with the client populations of each agency, on the whole the overlap was marked. I have grouped intervention for discussion into four broad categories: More formal therapeutic interventions that may or may not be evidence based, potentially manual based, and require formal training; Sensory based occupational therapy interventions, Typical developmental activities and Other ideas for intervention. The process of thinking about these interventions as groupings was difficult, some activities in the categories overlapped and the activities were not necessarily mutually exclusive. Cautionary Note: The application of any of the discussed interventions below, in the treatment of childhood trauma should only be done after conducting a comprehensive individual assessment and treatment plan to determine the specific needs of the client and analysis of appropriate and clinically indicated interventions. Also note that this is not an exhaustive list of potential therapeutic interventions for treating trauma in infants, children and adolescents, this is a list of observed/witnessed/experienced interventions as part of my Creswick Foundation Fellowship. Report for the Creswick Foundation Fellowship prepared by Michelle Taylor. 7

9 Formalised Therapies The clinical staff employed at services visited were masters level Mental Health Social Worker or PhD or Doctoral level Clinical Psychologists. Subsequently most of the direct therapeutic/clinical staff were well versed and trained in formal and traditional models of therapy such as Cognitive Behavioural Therapy (CBT) including relaxation skills training, Trauma Focused Cognitive Behaviour Therapy (TF-CBT), Play Therapy and Therapeutic Crisis Intervention (TCI) which includes the Life Space Interview. Given the focus of this report I will not go into detail about these, rather focussing on the more formal interventions that were new or being used much more at the outset of trauma treatment for children. It is important to note that rarely were clinicians using just one intervention technique, rather what I observed was more the delivery of a suite of developmentally matched interventions, relevant and rewarding for the child and done most successfully in the context of a relationship. It is important to note that at all residential care programs I visited there was a strong commitment to engaging and working with the families (biological and/or foster and/or kinship based) of the children in care. At some sites this was a formalised agreement as part of taking the child into treatment and at other sites an expectation of the families. For some of the residential care programs I visited, the children were living a long way from home, often in a different state from their family/adopted parents/foster families. I observed creative use of technology to engage parents in weekly child-focussed parent therapy/psycho-education, family therapy sessions and parent-child dyadic work through the use of Skype or other web based face-to-face communication mediums. I was also impressed by the importance placed on regular visits from families to the residential programs, parents especially. Many of these visits involved onsite stays for the parents with direct family and trauma and attachment informed parenting based therapeutic interventions from clinicians during these visits. Eye Movement Desensitization and Reprocessing One of the most consistently applied intervention techniques observed in all settings was the use of Eye Movement Desensitization and Reprocessing (EMDR). EMDR is a psychotherapy that addresses the overwhelming impact traumatic experiences have on normal cognitive and neurological coping mechanisms. EMDR aims to process distressing memories by reducing the effects of them to allow clients to develop new and more effective coping mechanisms. EMDR uses an eight-step protocol that includes clients recalling distressing memories while receiving one of several types of bilateral input, including side-to-side eye movement (Shapiro, 2001). EMDR is largely considered a sound evidence based treatment with over 20 randomized trials with adult populations demonstrating its efficacy in the treatment of Post-Traumatic Stress Disorder (PTSD). Creative Arts Therapies Also used consistently across all sites visited was the application of formal creative arts therapy programs including music therapy, art therapy, and journaling and dance therapy. Alexander Youth Network, Mount Saint Vincent Home and Hull Services all have distinct creative arts therapy programs. Mount Saint Vincent have a creative arts therapy team who provide art, music and movement and dance therapy; Alexander Youth Network an arts therapy program equipped with pottery kiln and Hull Services an arts therapy program at their school. Trauma-informed expressive and creative arts therapies provide opportunities for integration of neurodevelopmental knowledge and sensory experience (Malchiodi, 2012). Furthermore as survivors of trauma often struggle to create a language based narrative of their experiences, the provision of other expressive mediums can be valuable to assist in bridging sensory memories and a narrative. Cathy Malchiodi states trauma-informed expressive arts therapy is based on the idea that art expression is helpful in reconnecting implicit (sensory) and explicit (declarative) memories of trauma and in the treatment of PTSD (Malchiodi, 2012). Neurofeedback Sandhill Center and Cal Farley s are using Neurofeedback with their clients to assist in enhanced self-regulation skills. As discussed, trauma impacts the development and organisation of the stress response system in the brain often leaving clients with a state dependent overactive stress response (Perry et al 1995). Neurofeedback provides a process of biofeedback to retrain the brain in regulation of brainwave activity. Essentially Neurofeedback teaches the person what a specific brainwave feels like and how to turn those states on voluntarily (Hill & Castro, 2009). Sebern Fisher (2014) in her book on the use of Neurofeedback with developmental trauma, states that Neurofeedback training is Report for the Creswick Foundation Fellowship prepared by Michelle Taylor. 8

10 not just about quietening negative symptoms of trauma but about enhancing the potential of this person in all realms. In Neurofeedback sensors are placed on the client's head and ears. The sensors detect and send an amplified signal to a computer that analyses it and divides it into the brainwaves to increase (those associated with good focus and attention), and the brainwaves to decrease (those associated with poor focus, impulsiveness, anxiety or agitation). The Neurofeedback software uses these signals to drive a video game. The video game only moves forward (visual display changes, beeps are heard, points are scored) if the client increases the brainwaves associated with good focus, and decreases the brainwaves associated with inattention, anxiety or agitation. With repeated sessions, the brain learns to control attention and focus better. Training the brainwaves helps the brain to achieve a good balance between the different brainwaves. I had opportunity to observe Neurofeedback in session at Sandhill and was very impressed by the client s capacity to regulate her brain waves to move the video game along. The session I witnessed was approximately half way through the recommended 40 sessions that both services are using. Table 1: Interventions/activities being used by ChildTrauma Academy Flagship Sites visited. Intervention Sumner Mental Health Sandhill Centre Cal Farley s Boys Ranch Alexander Youth Network Mount Saint Vincent Home Hull Services Animal Assisted Therapy - Canine Trauma Focussed Equine Assisted Psychotherapy Animal Assisted Activities EMDR Play Therapy Sensorimotor Psychotherapy Family Therapy Therapeutic Crisis Intervention (TCI) Collaborative Problem Solving Neurofeedback Interactive Metronome Considering training staff and implementing Senior staff have just been trained SPARK (every morning min exercise) Relaxation Skills Training Massage Gardening Report for the Creswick Foundation Fellowship prepared by Michelle Taylor. 9

11 Art Activities/Therapy Dance Activities/Therapy Music Activities/Therapy Journaling Drumming Adventure Based Therapies (Kyaking, archery etc ) Ropses Courses Electronics/Rocket club Woodwork, Mechanics, Computing Occupational Therapy Floating Sensory Rooms/Space Sensory Doses Individual Sensory Boxes Exercise/Gym Swimming Bike Riding Walking Labyrinth Brain Breaks in Education Classrooms Animal Assisted Therapy Another very popular neurodevelopmentally informed intervention was the use of Animal Assisted Therapy (AAT). AAT is distinct from Animal Assisted Activities (AAA) due to the formal training required in appropriately using an animal in a therapeutic context to achieve targeted and measurable goals. AAT is much more than just patting a dog or grooming a horse. In AAT, the therapist will identify the therapeutic or clinical goals, and use the animal to help them achieve these goals. The Delta Society (USA) defines AAT as goal directed interactions with clearly defined and measurable outcomes. This distinguishes AAT from the less structured AAA (Lead The Way Website: Most of the services I visited were largely using canine or equine based AAT, although Mount Saint Vincent Home were skilfully using a guinea pig as well. The use of the animals in trauma therapy for clients appears largely to target relational or attachment issues. Specifically therapists use the interactional patterns and relationship development between client and animal to explore patterns of relating and develop skills to manage relationships more successfully. This form of AAT provides an alternative approach to addressing attachment issues in therapy. Report for the Creswick Foundation Fellowship prepared by Michelle Taylor. 10

12 The services I visited using Equine based AAT, tended to use one of two formalised training frameworks/models of Equine Assisted Psychotherapy, or a combination of them: Equine Assisted Growth and Learning Association (EAGALA) EAP and/or Tim Jobe and Bettina Schultz- Jobe s Natural Lifemanship, Trauma- Focussed Equine Assisted Psychotherapy (TF-EAP). EAGALA s EAP uses horses for emotional growth and learning. EAP is experiential in nature whereby clients learn about themselves and others by participating in activities with the horses, and then processing (or discussing) feelings, behaviours, and patterns. To practice EAP mental health professionals need to be licensed (in the U.S.) and properly qualified (outside the U.S.) to be involved. The focus of EAP is not riding or horsemanship but rather ground activities whereby clients apply different skills involving the horses such as: non-verbal communication, assertiveness, creative thinking and problem solving, leadership, and taking responsibility (EAGALA Website I was fortunate enough to meet Tim Jobe at the Denver University Human Animal Connection Trauma-Informed Animal-Assisted Interventions conference, where he and Bettina presented on their treatment model. TF-EAP is a model of EAP that uses both the physiology and the psychology of the horse to address specific therapeutic goals. At its core TF-EAP operates on the assumption that mental health issues impact intrapersonal and/or interpersonal relationships. TF-EAP rationale is informed by theory of brain development and trauma informed by the theoretical work of Dr. Bruce Perry, Dr. Bessel van der Kolk, and Dr. Frank Putnam. TF-EAP combines both mounted and groundwork using the horse to address the client s physiological and psychological responses to trauma. Unlike other animal assisted models of therapy, TF-EAP doesn t use the horse and the relationship with the horse as a metaphor, but rather as a partner in the healing process with the client connecting and building real relationships of trust and attunement with the horse (Natural Lifemanship website The TF-EAP model has two components: Relationship Logic and Rhythmic Riding. Relationship Logic consists primarily of groundwork whereby clients build a relationship with a horse that is truly based on a partnership. As the client and the horse are engaged in relationship building, real relationship patterns surface and can be addressed and transformed during TF-EAP sessions. Horses respond honestly to our behaviours and internal states making it easier for clients to recognise the problems they create in building a relationship with their horse. They can then recognize how they create those same problems in relationship with themselves and others and take appropriate responsibility and action to heal the relationships in their lives. Relationship Logic facilitates a process whereby clients are able to address and move through past or present damaging life circumstances, understand how those circumstances affect their current interactions, and make the personal changes necessary for healthy, fulfilling relationships in the present and future. (Spirit Reins Website: In Rhythmic Riding, TF-EAP utilises the rhythmic, patterned, repetitive, bilateral movement inherent in riding a horse to increase and reorganize the connections in the brain, thereby increasing the brain s ability for emotion and impulse control. The horse is able to provide the rhythm required to effectively heal the traumatised brain until the client is able to independently provide that rhythm. In effect, clients passively learn to self-regulate through the use of the rhythmic, patterned, repetitive movement of the horse." (Spirit Reins Website: While the horse provides a natural rhythm in its movement, Rhythmic Riding often incorporates riding in time to music. At Sandhill Center, Cal Farley s and Mount Saint Vincent Home, I participated in EAP both mounted and ground work. I both experienced and observed its direct benefits. Not only does being with the animal provide a sensory regulatory experience through the touch and feel of the animal, but more importantly I experienced the impact that mastering my own regulation had in the relationship and successful interactions with the horse. My observation and experience of AAT have left me confident of the invaluable role this intervention has in healing both regulation difficulties that result from trauma, but also in relational reparation work for attachment disruption and disorganisation. My experience is outlined in more detail in my blog ( & ). Sensorimotor Psychotherapy Dr Bessell Vander Kolk (1994) stated many years ago that the body keeps the score in relation to trauma. Referring to the physiological and sensory-based memories individuals make of traumatic experiences. In the years since, Pat Ogden has developed Sensorimotor Psychotherapy and her colleague Bonnie Goldstein has been using this model of therapy extensively with child populations. Sensorimotor Psychotherapy is fast becoming another very popular and sought after intervention in the treatment of trauma, specifically in terms of assisting clients to notice physiology, adjust posture and physiological presentation and the experience of doing so. Ogden et al (2006) claims that for clients to successfully process traumatic experiences, they must be in an optimal state of arousal the window of Report for the Creswick Foundation Fellowship prepared by Michelle Taylor. 11

13 tolerance. For the therapist, clinical intervention is about assisting the client develop or expand their window of tolerance and enhancing their skills to maintain themselves in this window. Sensorimotor therapy uses verbal therapy coupled with body centred interventions to both keep the client in their window of tolerance or bring them back within it and then process and integrate body and explicit memories of traumatic events (Ogden et al, 2006). Sandhill Center are using and incorporating the concept of the window of tolerance and body oriented intervention in their treatment approaches with clients. Interactive Metronome In Calgary Canada, Hull Services introduced me to something I d not heard of before, the Interactive Metronome (IM). Partnering with a local chiropractor, Hull Services are trialling the use of IM intervention with a small group of children in their Preadolescent Residential Treatment Program. Stanley Greenspan developed IM in the early 1990s. As an intervention it works to improve temporal processing in the brain. Temporal processing plays a role in detecting where sound comes from, for assisting us in sleep wake cycles and focussing attention, reading comprehension, elements of memory, speech processing and motor coordination (Greenspan 2002). IM aims to address deficient neural timing within and between regions of the brain that underlie many problems such as attention/concentration; motor planning and control; language processing; sequencing and timing skills; coordination; balance/gait; endurance and strength and cognitive processing abilities. Basically it aims to improve the synchronicity of the internal clock and neural communication (Greenspan 2002). The IM is a game like auditory-visual platform that operates on a computer providing the client immediate and constant feedback in relation to their synchronised timing in the brain. I was able to observe an IM session with three children at Hull. During the session the child wears headphones and listens to a recurring beat. The child either clapped or tapped his/her foot to the beat. They have a glove or mat with sensors that provide a record of how close s/he comes to the exact beat. With the visual cues of performance they get immediate feedback in relation to their accuracy in timing and can make in the moment adjustments to performance, thus like neurofeedback, retraining this skill in the brain. Over the course of sessions the IM protocol increases in complexity to enhance neural timing skills. To date there has been one study done of the IM with 56 male ADHD clients 6 12 years of age and found improvements in many areas including attention (Shaffer et al 2001). Hull Services are at the beginning of this project and while nothing has been formally assessed they are reporting marked clinical improvements in individual children s language skills, motor planning and control and attention abilities. Collaborative Problem Solving None of the sites I visited were using Collaborative Problem Solving (CPS) at the time I was there, but some had commenced training and there were a lot of conversations being had about it. CPS, originally conceived by Dr Ross Greene and currently disseminated by the Massachusetts hospital Think Kids Program and Dr Stuart Ablon, is an approach to scaffolding children s behaviour in a developmentally informed manner. CPS operates on the basic tenet that many of the difficulties children present with are best understood as the child lacking the skills required to handle a situation, particularly the thinking skills, and that they are best addressed by teaching the skills that are lacking (Greene & Ablon 2003; 2006). I saw Dr Ablon present on CPS at the Inaugural NMT Symposium and was impressed by the CPS catch phrase they lack the skill NOT the will. While Dr Ablon and Dr Perry claim that the CPS model involves a rhythmic and relational interchange between adult and child, and that it does in the to and fro of the problem solving process, I believe however, that the primary process of regulating the child remains paramount, before the child will actually benefit from the solution/problem solving negotiation component of CPS. CPS provides an alternate model to those resulting in restraint such as TCI when dealing with challenging behaviours in children; it is neurobiologically and developmentally respectful, has a strong evidence base and could show great promise in helping those working with children and young people remember that it s a lack of skill not will. Report for the Creswick Foundation Fellowship prepared by Michelle Taylor. 12

14 Sensory Based Interventions It was a surprise to me that only AYN, Hull Services and MSV talked openly about the use of regular Occupational Therapy (OT) as a formal sensory intervention for their clients. Each agency uses OTs for assessment of client need and intervention to address such. Hull Services access OT for their clients on a case by case special consideration request and when they do so, they seek the services of Occupational Therapists who have an understanding of NMT so to provide neurodevelopmentally informed OT intervention. MSV and AYN formally use massage as an intervention with onsite volunteer masseuses. MSV in particular have a full time volunteer masseuse who provides a wide range of clothed massage, Bach flower remedies and other alternative therapies with their clients. They call this their tactile therapy program. Despite only three of the agencies formally using occupational therapists input, all of the services visited used some form of sensory box idea. In many of the residential units and school programs each child had their own sensory box that they could use to self regulate. Hull Services were also using a program of rotating sensory bins (for example contents see Appendix A) in both their school and preadolescent treatment program. At the school they were scheduling sensory breaks every 20 minutes depending on class teacher and at the Preadolescent Treatment Program offering sensory doses four times a day, in the morning, after lunch, after school and a settling sensory dose in the evening before bed. The concept of the sensory bin dosing is to have a tub of sensory activities that the children can use and access during the sensory break see appendix A. It is important to state that all sensory breaks and doses observed were carried out in the context of staff and child interaction and relationships. Hull Services have also developed sensory rooms in both their school and preadolescent treatment program. These rooms provide a variety of sensory-based seating, sound and lighting options for clients to use to regulate themselves. Rarely however do the children use these rooms alone, often accompanied by an adult for co-regulation. Typical Developmental Activities When it comes to typical developmental activities the list of interventions or activities really is endless. The trick here is for the child and adolescent welfare sector to think about typical developmental experiences of infancy and early childhood that clients may have missed out on and find developmentally appropriate and where needed chronologically respectful ways to provide those experiences. One of the most common typical developmental activities that every service I visited was doing was exercise. Specifically taking their lead from John Ratey s SPARK (2009), which argues that 20 minutes of exercise each morning enhances learning capacity, most of the schools I visited with provided students at least 20 minutes of exercise before commencing classes every morning. Furthermore many of the programs provided regular bike riding opportunities, including formal bike programs, walking, swimming, and other physical exercise based activities. Dr Rick Gaskill has done some fantastic work compiling detailed lists of activities that are primarily somatosensory, social/relational and cognitive. Dr Gaskill provided me a draft copy of this work and it is my understanding that he is working together with Dr Perry to publish this. Examples of some of the suggested somatosensory activities suggested by Dr Gaskill include but are not limited to: rocking, hugs, swaddling, song chants, listening to nature sounds, dancing to favourite music, washing and brushing hair, reading books, yoga, martial arts, drumming, hand stacking games and such. Examples of social/relational activities include: walking together, exploring facial expressions and what they mean; animal assisted activities like pet pals, communication skills training, labyrinths, joint Lego or model work, mask making of different expressions and feelings, turn taking game playing and such. Examples of cognitive activities include: games like charades, scrabble, hangman, guess who, self esteem work using art or other self esteem interventions, story writing and telling, games to practice delaying gratification and regulating emotional distress from that, building something or making something from the instructions of another and such. MSV have produced a Creative Arts Therapy resource called Doodles Dances and Ditties (2014). This book provides a range of activities and games that can be used for sensory integration, self-regulation, relational and cognitive interventions. This book can be purchased via the MSV website ( Hull Services also showcased a new resource they have developed and is currently in production called Brain Boosters. Brain Boosters is a box of activity cards. Each card provides an activity and the box is divided up akin to Doodles Ditties and Dances into sensory integration, self regulation, relational and cognitive interventions. The Brain Boosters can be pre ordered via Hull Services ( Report for the Creswick Foundation Fellowship prepared by Michelle Taylor. 13

15 Other Activities Sandhill Center is trialling an old technique of intervention to enhance physiological regulation using a floatation tank, sometimes referred to as sensory deprivation. The floatation process involves floating in a darkened tank with little auditory or visual input in Epsom salt infused water at body temperature. The rational for floatation is that with a reduction in external bodily sensation there is potentially a corresponding reduction in autonomic nervous system arousal, a reduction in the body s stress response system including reduced heart rates, blood pressure and slower breathing. Hence the provision of the float experience provides an altered state of arousal and regulation. (Hutchinson, 1984). I had opportunity to experience a float at Sandhill. The floatation experience absolutely induced a state of relaxation in me and there were demonstrated physiological changes in my heart rate. However, I found this an isolating experience and my initial anxieties in relation to the tank required me to self regulate using cognitive self talk and cognitive awareness of my arousal levels. I think this process has some merit and certainly Sandhill are seeing marked physiological changes in the children who use it. That said they have children who do not like or use the float process and it would be interesting to get more information as to their reasons for this. As indicated in my blog, I am unsure of the benefit for this with traumatised children. For more information about my experience see my blog entry Other activities used by many of the agencies I visiting included gardening programs, drumming circles, adventure based therapies, ropes courses, labyrinths and group/teamwork based programs such as electronics, building rockets, woodwork, music recording, mechanics and computing. Mobius Tile and Grout Berry Street s Take Two program has been familiarising itself with and trialling the use of Dr Brandt s Mobius Tile and Grout Model (Brandt 2011) of intervention planning. Dr Brandt has developed the Mobius concept to refer to an intervention plan for clients that has no beginning and no end. Essentially there are 168 hours in each week and the Mobius Tile and Grout model serves to plan for hour by hour activities/intervention for a child and parent that scaffolds their developmental progress within the context of the child s chronological, developmental, and functional age, through enlisting the unique resources that environment affords (Brandt 2014). The Mobius: Tile and Grout model holds much promise for thoughtfully planned schedules that ensure wrap around therapeutic care/intervention for traumatised children and does so in the context of rich and informed relational networks. Report for the Creswick Foundation Fellowship prepared by Michelle Taylor. 14

16 4. Reflections and Conclusions Education: Implications for enhanced learning. Each of the residential programs I visited had education based services onsite. On the whole, with the exception of the Boys Ranch Independent School District, there was a consistent approach to neurodevelopmental and trauma informed principles in teaching. Cal Farley s school programs run as an independent schools district, making the overarching theoretical models used by Cal Farley s somewhat separate from their education programs. Thus much like Berry Street and Take Two, they have to engage in a process of education, training and support for the Boy s Ranch School District to take up more neurodevelopmental and trauma sensitive approaches to learning. Leaving Cal Farley s aside, each of the school programs visited commenced their day with at least 20 minutes of physical activity and exercise (Ratey & Hagerman 2009). Classrooms were structured based on developmental rather than chronological age, and regular repetitive brain breaks (Lengel & Kuczala, 2010), be that with sensory bin/box activities, outdoor play and exercise or just being able to get up and move around the room were readily available to students. While many of these brain breaks where scheduled and planned in a timely manner, what I also observed however was the importance of teaching staff being attuned to the mental state of their students and intervening with co-regulatory brain breaks before students became disengaged or disruptive. Teachers and principals were aware of and committed to the importance of consistent affect and autonomic nervous system regulation throughout the day and prioritised this as a key element of their teaching and for the children s learning. At AYN s school I witnessed a teacher take the principles of movement, sensory input, rhythm and pleasure and incorporate this into the curriculum, teaching the mathematics concepts of greater than and less than and counting by fives in an interactive, physical and movement based way that was playful and engaging for the students. This then meant that in addition to scheduled brain breaks ; this teacher was able to regulate her students while teaching them. The challenges faced by Cal Farley s are probably more directly transferrable to the Australian education context than onsite education programs for residential treatment centres. We find ourselves trying to influence mainstream schools to incorporate trauma sensitive approaches to teaching. While we may not be able to reorganise classrooms by developmental age groupings, other techniques observed during the Fellowship are in fact transferrable. For instance, in the past two years Berry Street s Childhood Institute has been working together with the Morwell Primary School to incorporate patterned, repetitive, rhythmic movement and music activities into daily classroom schedules in their Rhythm Project. Unlike the education programs witnessed in the USA and Canada, Morwell Primary School are applying these patterned repetitive activities in mainstream classes of 23 students and one teacher, hence applying the activities in a whole of class approach at regular intervals and on the surface appear to be doing so with considerable success. Formal evaluation of the Rhythm Project is being undertaken, however preliminary observations suggest that brain breaks can be applied to whole of class, thus vulnerable children do not have be singled out for intervention. Teachers of the grades prep to four classes at Morwell Primary report that the provision of regular movement and music breaks for their students has an impact on student s attention span and learning capacity. Calmer Classrooms (Downey 2007) as both a document and the training offered by Berry Street s Take Two training team provided the Victorian education system with a theoretical overview and understanding of trauma, attachment disruption and the impact this has on learning. It also provided strategies for creating a relationally connected and safe classroom. This resource potentially provides a wonderful platform from which to introduce the inclusion of patterned repetitive movement, sensory activities and rhythm into the classroom environment. Current research and my fellowship observations suggest that an education system that reintroduces exercise every morning and learning coupled with regular and repetitive brain breaks that afford affect regulation experiences are likely to have more regulated classrooms, more attentive students and ultimately better learning outcomes. Overarching Theoretical Models All the residential treatment centres, community mental health programs and alternate education services I visited operated with clear theoretical frameworks driving their service delivery, irrespective of program variability. While many of the agencies had various programs within it, they were essentially all servicing the same client group and as a result did so with central, agency-wide, theoretical frameworks for practice. While my visits tended to focus on the role of NMT as a theoretical framework, this was not the only model being used by agencies and incorporation of NMT and other models together to drive the agency theoretical framework was evident. Report for the Creswick Foundation Fellowship prepared by Michelle Taylor. 15