A Day in the Life. Tasha - age 16. Response? Embedding Attachment Theory and Research in Practice: Children s Residential Treatment April 25, 2007

Transcription

1 Center for Excellence in Children s Mental Health Embedding Attachment Theory and Research in Practice: Children s Residential Treatment April 25, 2007 Krista Nelson LICSW LMFT- Project Coordinator Wilder Center for Children with Reactive Attachment Disorder kmn2@wilder.org Kevin age 8 Aggressive rages toward grandmother Low frustration tolerance Easily irritated by peers Early history of neglect Witnessed violence to mother Multiple placements ADHD, Bi-polar diagnoses Caregivers exhausted, fearful, see a bad kid A Day in the Life Tasha - age 16 Response? Adopted from Russia- age 8 Witnessed frequent sexual activity, experienced physical abuse from adults until mother s death when age 6 Orphanage placement Responded to attachment-focused parenting/therapy initially when adopted by invested single parent Adolescence- changes in body and social environment Cruel, oppositional behavior toward mom Attention from male peers for sexualized behavior Oppose teachers by day, cling to mom by night Sleep difficulties, school refusal Unresponsive to punishment or incentives Mother- hostage in own home- own trauma reactions In home assessor sees lack of parent-child hierarchy Candidates for Residential Treatment? How would removing from home make lasting impact on behavior? How make sense of myriad of issues to determine treatment direction? How does attachment theory and research increase capacity to stabilize or even understand these youth? Wilder Foundation- Children s Residential Services Do Institutions and Families Mix? Oliver Twist, Little Orphan Annie? 58 youth, age 5-18, in 7 group living environments 90%- trauma exposure In 4 th out of home placement/average 76 % returned to community/family at discharge (2000-1) Center for Children with Reactive Attachment Disorder- 126 youth ( ) Tracks treatment of youth with diagnosis or clinically significant RADQ 1

2 Wilder Residential Treatment today Paradox- use out of home placement to preserve or shift attachment relationships All children in out of home placement, regardless of diagnosis have attachment disruptions Good milieu therapy share same qualities as attuned and proactive care in secure attachment relationships Craft environment or way of working that could increase youth s ability to use adults for comfort, structure and learning, even when away from intimacy of family 2

3 Guiding Principles- Research to Practice Human Being Learn and Grow in Context of Relationships RTC remains intense intervention reserved for youth who cannot progress without all encompassing environment that provides containment, safety, structure to internally terrorized who can t cope with developmental demands of later childhood. Milieu is heart of RTC- engages in adult and peer relationships Reinstate more adaptive developmental path Life skills practice/competence Adults structure, engage, nurture and challenge youth Regression is expected, invited Discharge planning begins at intake- family/community involvement- essential Multi-Sensory Approach to Shifting Expectencies Therapy as Dancing Lessons Reactivate attachment partnership through sensory exchange Practice secure attachment behaviors Experiential methods (play, art, drama to build felt security Integrating effects of Trauma in storytelling family connection, EMDR Get medication levels right in 1 st months of placement Scaffolding - organizing child s experience Know child s developmental ages and parts of self to promote constancy Meet needs of age expressed Co-regulate impulses and emotions Model mentalizing - reflecting on states to engage in problem-solving, awareness of other Parents practice in family therapy Attachment Focused Treatment Design Journey through Placement Milieu Therapy Structure-Engage-Nurture-Challenge Individual Therapy Awaken Senses-Self Identity- Emotional Regulation-Trauma Integration Family Therapy Skills of Family Living, Attachment Exchanges, Relational Repair through Narratives Kevin- Bush Children s Center Tasha- Holcomb House Clients of Center for Children with RAD Working with the Diagnosis- mosaic of issues 3

4 Family Relationship Treatment Goals Milieu Therapy in Group Living Move from Control to Range of Self Expression Accept adult as source of care and guidance/limits Adult can help with problem-solving Safe ways to release energy/feelings Stop and think before acting on impulses Tolerate feeling Play with peers in give & take manner Extend care to other Age appropriate social activity Nurture- Give and Take in ways that feel good Structure- Establish safe environment Engage- Positive attention from consistent caregivers Challenge- Teaching life skills for accepting limits, calming and managing self and communicating respectfully to others Individual Therapy Family Therapy Process Therapist s job- teen s job Awaken senses in exploration Box making- containment Self calming plan Parts of self collage Theraplay games practice arousal/calming Storytelling- EMDR- Suffering Skin Letter to birthmother, Kevin s toads, DBT for Tasha- thinking differently Create a for secure base for family members in RTC Gather attachment histories- shark music Contain resentmentdetaching Practice attachment behavior exchanges Therapeutic Stories- EMDR Challenge behaviors as tolerate shame/anger Prepare for transition home Adult Job Child Job Results of Attachment Repair? Emotionally available Warmth/Empathy Comfort Protect Play Teach Structure/Routine Limits/Discipline Regulate own emotions Be Dependent- Trust Seek out comfort Vigilant against danger to self/adult Play Learn/Master new things Motivated to take risks Independent Shift child s map for how relationships are supposed to go Build scaffolding - Use storytelling and repetitive experience to organize self Celebrate signs of connection daily Child is building layers of security and success Self regulation mentalizing & reflective function capacities enhanced 4

5 Outcomes to Date- Five years into Project Center client progress tracked through consultation and written quarterly reports 92% of Center clients with clinically significant RADQs at intake had scores in normative range at discharge between Kevin s Story Tasha s Story What s Working for Children and Families? I ve learned that you shouldn t go through life with a catcher s mitt on both hands. You need to be able to throw something back. I ve learned that even when I have pains, I don t have to be one. I ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel. Maya Angelou 5