ND Conference Complex Trauma Treatments · PTSD Symptom Reduction (Outpatient, Residential) Child...

Hilary Hodgdon, Ph.D. – Complex Trauma in Children 1

Complex Trauma Complex Trauma

TreatmentsTreatments

The Problem of Treating Complex TraumaThe Problem of Treating Complex Trauma

�� Need for intervention that:Need for intervention that:

�� Can address continuum of exposures (layers of Can address continuum of exposures (layers of chronic and acute), including ongoing exposurechronic and acute), including ongoing exposure

�� Is embedded in a social/contextual frameworkIs embedded in a social/contextual framework

�� Is sensitive to individual developmental Is sensitive to individual developmental competencies and vulnerabilities, and flexible in competencies and vulnerabilities, and flexible in its approachits approach

�� Addresses individual, familial, and systemic Addresses individual, familial, and systemic needs and strengthsneeds and strengths


CORE ComponentsCORE Components

What are Evidenced Based Treatments?What are Evidenced Based Treatments?

��Treatments that have strong research supportTreatments that have strong research support

��Clinical trials & Randomized Controlled Clinical Clinical trials & Randomized Controlled Clinical

TrialsTrials

��Typically involve a manual, series of training and Typically involve a manual, series of training and

consultation to learn the treatment modelconsultation to learn the treatment model


EBTEBT’’ss for Complex Traumafor Complex Trauma

��TraumaTrauma--Focused Cognitive Behavioral Therapy Focused Cognitive Behavioral Therapy

(TF(TF--CBT)CBT)

��ChildChild--Parent Psychotherapy (CPP)Parent Psychotherapy (CPP)

��Attachment, SelfAttachment, Self--Regulation and Competency Regulation and Competency

(ARC)(ARC)

��ParentParent--Child Interaction Therapy (PCIT)Child Interaction Therapy (PCIT)

��Seeking SafetySeeking Safety

��Trauma Systems TherapyTrauma Systems Therapy

��And many moreAnd many more……. .

EBT TrainingEBT Training

Trauma EBT developers and experts believe in order Trauma EBT developers and experts believe in order for a clinician to be considered trained the following for a clinician to be considered trained the following criteria are needed: criteria are needed:

��TwoTwo--day basic training, monthly consultation for 12 day basic training, monthly consultation for 12 months by a certified EBT trainermonths by a certified EBT trainer

��Weekly supervision by an agency EBT trained Weekly supervision by an agency EBT trained supervisor who monitors clinician fidelity to the supervisor who monitors clinician fidelity to the modelmodel

�� Implementation of the model with a minimum of 3 Implementation of the model with a minimum of 3 families per year.families per year.


Trauma Focused Cognitive Trauma Focused Cognitive

Behavioral Therapy Behavioral Therapy

(TF(TF--CBT)CBT)

TFTF--CBTCBT��Model Developed by Cohen, Model Developed by Cohen, MannarinoMannarino, & , &

DeblingerDeblinger

��An EvidenceAn Evidence--Based PracticeBased Practice

��A SAMHSA Model ProgramA SAMHSA Model Program

��One of Kaufman Best PracticesOne of Kaufman Best Practices


TFTF--CBT: A hybrid treatment model that integrates:CBT: A hybrid treatment model that integrates:

�� Trauma sensitive interventionsTrauma sensitive interventions

�� CognitiveCognitive--behavioral principlesbehavioral principles

�� Attachment theoryAttachment theory

�� Developmental NeurobiologyDevelopmental Neurobiology

�� Family TherapyFamily Therapy

�� Empowerment TherapyEmpowerment Therapy

�� Humanistic TherapyHumanistic Therapy

TFTF--CBT: The EvidenceCBT: The Evidence

�� Model initially tested:Model initially tested:�� DeblingerDeblinger et al (1990). Journal of American Academy of Child and et al (1990). Journal of American Academy of Child and

Adolescent Psychiatry, 29, 5, 747Adolescent Psychiatry, 29, 5, 747--752752�� Stauffer & Stauffer & DeblingerDeblinger (1996). Child Maltreatment, 1, 65(1996). Child Maltreatment, 1, 65--76.76.

�� Randomized controlled trials:Randomized controlled trials:�� DeblingerDeblinger et al, (1996). Child Maltreatment, 1, 4, 310et al, (1996). Child Maltreatment, 1, 4, 310--321.321.�� Cohen & Cohen & MannarinoMannarino (1996). Journal of American Academy of (1996). Journal of American Academy of

Child and Adolescent Psychiatry, 35, 1, 42Child and Adolescent Psychiatry, 35, 1, 42--50.50.�� Cohen & Cohen & MannarinoMannarino (1998). Child Maltreatment, 3, 1, 17(1998). Child Maltreatment, 3, 1, 17--26.26.�� DeblingerDeblinger et al (2001). Child Maltreatment, 6, 4, 332et al (2001). Child Maltreatment, 6, 4, 332--343.343.�� Cohen & Cohen & MannarinoMannarino (1997). JAACAP, 36, 9, 1228(1997). JAACAP, 36, 9, 1228--1235.1235.�� Cohen & Cohen & MannarinoMannarino (1998). JAACAP, 37, 1, 44(1998). JAACAP, 37, 1, 44--51.51.�� DelbingerDelbinger, et al, (1999). Child Abuse and Neglect, 23, 12, 1371, et al, (1999). Child Abuse and Neglect, 23, 12, 1371--

1378.1378.�� King, et al (2000). JAACP, 59, 1, 1347King, et al (2000). JAACP, 59, 1, 1347--1355.1355.


TFTF--CBTCBT

TFTF--CBT maintains the following treatment focus:CBT maintains the following treatment focus:

PRACTICEPRACTICE

��PPsychoeducationsychoeducation and Parenting Skillsand Parenting Skills

��RRelaxationelaxation

��AAffective Expression and Regulationffective Expression and Regulation

��CCognitive Copingognitive Coping

��TTrauma Narrative Development and Processingrauma Narrative Development and Processing

�� IIn Vivo Gradual Exposuren Vivo Gradual Exposure

��CConjoint Parentonjoint Parent--Child SessionsChild Sessions

��EEnhancing Safety and Future Developmentnhancing Safety and Future Development

TFTF--CBT: Affect ExpressionCBT: Affect Expression


TFTF--CBT: SUDSCBT: SUDS

TFTF--CBT: Processing (8 CBT: Processing (8 yoyo))


Child Parent Psychotherapy Child Parent Psychotherapy

(CPP)(CPP)

CPPCPP

�� Targets children (ages 0Targets children (ages 0--5 years) 5 years)

and caregivers.and caregivers.

�� Heavy emphasis on dyadic work.Heavy emphasis on dyadic work.

�� Developed by Alicia Lieberman, Ph.D., Developed by Alicia Lieberman, Ph.D.,

Patricia Van Horn, J.D., Ph.D., Patricia Van Horn, J.D., Ph.D.,

Chandra Chandra GhoshGhosh--IppenIppen, Ph.D., Ph.D.

�� UCSF Child Trauma Research ProjectUCSF Child Trauma Research Project

�� An EvidenceAn Evidence--Based PracticeBased Practice

�� A SAMHSA Model ProgramA SAMHSA Model Program


CPP: The EvidenceCPP: The Evidence

�� Randomized controlled trials:Randomized controlled trials:

�� CicchettiCicchetti, D. et al, (2000). JOACP, 28, 135, D. et al, (2000). JOACP, 28, 135--148.148.

�� CicchettiCicchetti, D. et al, (2006). Development and Psychotherapy, 18, , D. et al, (2006). Development and Psychotherapy, 18, 623623--650.650.

�� CicchettiCicchetti, D. et al, (1999). Attachment and Human Development, , D. et al, (1999). Attachment and Human Development, 1, 341, 34--66.66.

�� Lieberman, A.F. et al, (2005). JAACAP, 44(12), 1241Lieberman, A.F. et al, (2005). JAACAP, 44(12), 1241--1248.1248.

�� Lieberman, A.F. et al, (2006). JAACAP, 45(8), 913Lieberman, A.F. et al, (2006). JAACAP, 45(8), 913--918.918.

�� Lieberman, A. F. et al, (1991). Child Development, 62, 199Lieberman, A. F. et al, (1991). Child Development, 62, 199--209.209.

�� TothToth S.L. et al, (2002). Developmental Psychopathology, 14, 877S.L. et al, (2002). Developmental Psychopathology, 14, 877--908.908.

�� TothToth, S. L. et al, (2006). Journal of Consulting and Clinical , S. L. et al, (2006). Journal of Consulting and Clinical Psychology,74(6), 1006Psychology,74(6), 1006--10161016

CPPCPP�� A hybrid treatment model that A hybrid treatment model that

identifies the following goals:identifies the following goals:

�� To support and strengthen the To support and strengthen the

caregivercaregiver--childchild’’s relationship as a s relationship as a

vehicle for restoring and protecting vehicle for restoring and protecting

the childthe child’’s mental health. s mental health.

�� Improve the caregiversImprove the caregivers’’ and and

childrenchildren’’s maladaptive s maladaptive

representations of themselves and representations of themselves and

each other and interactions and each other and interactions and

behaviors that interfere with the behaviors that interfere with the

childchild’’s mental health. s mental health.


CPPCPP

�� ChildChild--parent interactions are the focus of six intervention parent interactions are the focus of six intervention

modalities:modalities:

�� Promoting developmental progress through play, Promoting developmental progress through play,

physical contact and language.physical contact and language.

�� Offering developmental guidance.Offering developmental guidance.

�� Modeling appropriate protective behavior.Modeling appropriate protective behavior.

�� Interpreting feelings and actions.Interpreting feelings and actions.

�� Providing emotional support/empathetic Providing emotional support/empathetic

communication.communication.

�� Offering crisis intervention, case management and Offering crisis intervention, case management and

concrete assistance with problems of living.concrete assistance with problems of living.

Attachment, SelfAttachment, Self--regulation regulation

and Competency (ARC)and Competency (ARC)


Where does ARC come from?Where does ARC come from?

�� Translation of clinical principles across settings Translation of clinical principles across settings

(out(out--pxpx, residential, school, home, residential, school, home--based)based)

�� OrOr……what is it that we actually do?what is it that we actually do?

�� ““EvidenceEvidence--based practicebased practice””??

�� OrOr……how to fit real kids into scientific boxeshow to fit real kids into scientific boxes

�� Staying true to the inner clinicianStaying true to the inner clinician

�� OrOr……keeping the art in keeping the art in ttrreeaa ttmentmentrr

Protocol vs. Component based Protocol vs. Component based

InterventionsInterventions

�� Clinical Objectives FocusedClinical Objectives Focused

�� Developmentally TailoredDevelopmentally Tailored

�� Context SpecificContext Specific

�� Individual TargetsIndividual Targets

�� MenuMenu--DrivenDriven


ARC: A Framework for Intervention ARC: A Framework for Intervention

with Complexly Traumatized Youthwith Complexly Traumatized Youth

�� Core principles of understandingCore principles of understanding::

�� Trauma derails healthy developmentTrauma derails healthy development

�� Trauma does not occur in a vacuum, nor Trauma does not occur in a vacuum, nor

should service provisionshould service provision

�� Good Good ““interventionintervention”” goes beyond individual goes beyond individual

therapytherapy

Systemic

Familial

Individual

ATTACHMENT

•Caregiver affect management

•Attunement

•Consistent response

•Routines and Rituals

REGULATION

•Affect Identification

•Modulation

•Affect Expression

COMPETENCY

Primary Components

•Executive functions

•Self development

ARCARC: :

A Framework A Framework

For For

Intervention Intervention

with with

Complexly Complexly

Traumatized Traumatized

YouthYouth

Blaustein & Kinniburgh, 2010;

Kinniburgh & Blaustein, 2005

TRAUMA EXPERIENCE

INTEGRATION


ARC ARC -- 10 Building Blocks10 Building Blocks

Caregiver

Affect

Mgmt.

Attunement Consistent

Response

Routines

and

Rituals

Affect

IdentificationModulation Affect

Expression

Self Dev’t

& Identity

Executive

Functions

Trauma

Experience

Integration

Attachment

Self-

Regulation

Competency

Who does ARC target?Who does ARC target?

�� Designed to target the needs of children, Designed to target the needs of children,

families, and systems impacted by complex families, and systems impacted by complex

traumatrauma

�� Core domains translate across children/ families/ Core domains translate across children/ families/

systems; applications and goals will varysystems; applications and goals will vary

�� Crucial importance of: Crucial importance of:

�� Keep an eye on the clinical objective, rather than the Keep an eye on the clinical objective, rather than the

techniquetechnique

�� Pay attention to relative goals and relative successesPay attention to relative goals and relative successes

�� Have a plan, but catch the momentsHave a plan, but catch the moments


Programs Applying ARC PrinciplesPrograms Applying ARC Principles�� Anchorage CMHC (OutAnchorage CMHC (Out--pxpx))

�� Beth Israel NY (OutBeth Israel NY (Out--pxpx, school, school--based)based)

�� B.C. ChildrenB.C. Children’’s Hospital (Ins Hospital (In--pxpx))

�� Bethany Christian Services (OutBethany Christian Services (Out--pxpx))

�� Butler Center (DYS residential)Butler Center (DYS residential)

�� Calgary Public Schools (Classroom / Calgary Public Schools (Classroom / wholewhole--school)school)

�� ChildrenChildren’’s Hospital L.A. (Highs Hospital L.A. (High--risk risk youth programs)youth programs)

�� The ChildrenThe Children’’s Guild (Therapeutic s Guild (Therapeutic foster care)foster care)

�� CohannetCohannet Academy (DMH IRTP)Academy (DMH IRTP)

�� CrittentonCrittenton ChildrenChildren’’s Services (Multiple s Services (Multiple programs programs –– outout--pxpx, Head Start, Group , Head Start, Group Home)Home)

�� DV Crisis Center (DV Shelter and DV Crisis Center (DV Shelter and Advocacy)Advocacy)

�� GatewayGateway--Longview (Child Welfare Longview (Child Welfare Agency)Agency)

�� GlenhavenGlenhaven Academy (Residential Academy (Residential School)School)

�� Harmony Hill (Residential treatment)Harmony Hill (Residential treatment)

�� Hertfordshire County Council Hertfordshire County Council (Adolescent programs)(Adolescent programs)

�� House of Mercy (Domestic Violence House of Mercy (Domestic Violence shelter program)shelter program)

�� Kennedy Krieger (Therapeutic Foster Kennedy Krieger (Therapeutic Foster Care Program)Care Program)

�� La La RabidaRabida ChildrenChildren’’s Hospital (Outs Hospital (Out--pxpx))

�� Lower Naugatuck Valley PCRC (DV Lower Naugatuck Valley PCRC (DV Resource Center)Resource Center)

�� Mosaic ChildrenMosaic Children’’s Services (Group s Services (Group Home)Home)

�� MGH Chelsea (Group/OutMGH Chelsea (Group/Out--pxpx))

�� New England Counseling & Trauma New England Counseling & Trauma Center (OutCenter (Out--pxpx))

�� Safe from the Start (CommunitySafe from the Start (Community--based based agencies)agencies)

�� Southern Trust (Residential / group Southern Trust (Residential / group homes)homes)

�� SutterSutter--Yuba Mental Health (OutYuba Mental Health (Out--pxpx))

�� The Trauma Center at JRI (OutThe Trauma Center at JRI (Out--pxpx))

�� UCSF/CASARC (OutUCSF/CASARC (Out--pxpx))

�� Vermont Department of Mental Health Vermont Department of Mental Health (Outpatient programs)(Outpatient programs)

�� Youth on Fire (Adolescent dropYouth on Fire (Adolescent drop--in in center)center)

Treatments Utilized in the NCTSNTreatments Utilized in the NCTSN

63.88.3

4.5

3.5

2.5

17.4

TF-CBT

ARC

CPP

PCIT

SPARCS

Other /Unknown

NCTSN FY 2010 Annual Progress Report – Executive Summary

Total n=966


Restraint ReductionRestraint ReductionMonthly Restraint Totals 2006-2007

0

5

10

15

20

25

30

35

40

45

50

butler 7 18 2 9 8 5 8 1 6 4 3 4 4 0 3 2 1 1 7 7 6

cohannet 28 20 44 44 31 42 19 15 20 15 8 8 6 5 10 0 6 4 14 15 4

glenhaven 41 22 33 24 22 23 19 13 11 11 8 12 7 15 13 5 3 6 5 3 14

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

2006 2007

Restraint ReductionRestraint Reduction

Average Percent Reduction in Restraint Per Bed Capacity

FY 06 - FY 07

54%

-20%-40%

-20%

0%

20%

40%

60%

80%

100%

Glenhaven, Cohannet, Butler Other JRI Residential Treatment Programs

Pe

rce

nt

Re

du

cti

on

in

Re

str

ain

ts P

er

Be

d C

ap

ac

ity


66--Month Change in CBCL ScoresMonth Change in CBCL Scores

545556575859606162636465666768

Baseline 3 Months* 6 Months*

TF-CBT

ARC

SPARCS


*Significant decreases on CBCL scores; no significant differences across interventions

66--Month Change in UCLA PTSDMonth Change in UCLA PTSD--RI RI

ScoresScores

15

17

19

21

23

25

27

29

Baseline 3 Months* 6 Months*

TF-CBT

ARC


*Significant decreases on CBCL scores; no significant differences across interventions


ARC Treatment Outcomes to DateARC Treatment Outcomes to Date

�� PTSD Symptom Reduction (Outpatient, PTSD Symptom Reduction (Outpatient, Residential)Residential)

�� Child Behavior Improvement (CBCL) Child Behavior Improvement (CBCL) ((Outpt/ResiOutpt/Resi))�� Outpatient (85%percentile to 50% percentile)Outpatient (85%percentile to 50% percentile)

�� Residential (sig reduction Externalizing Problems; Residential (sig reduction Externalizing Problems; positive trend Internalizing)positive trend Internalizing)

�� Significant Restraint Reduction (JRI)Significant Restraint Reduction (JRI)

�� Significant increase in Placement Permanency Significant increase in Placement Permanency (92% vs. under 50%) (ACMHS)(92% vs. under 50%) (ACMHS)

�� Increased staff perceived competence, reduced Increased staff perceived competence, reduced staff burnout and turnover (VTstaff burnout and turnover (VT--DMH)DMH)

ARC Intervention ComponentsARC Intervention Components

�� Integration into clinical work (structured and Integration into clinical work (structured and unstructured); individual and/or dyadic unstructured); individual and/or dyadic applicationapplication

�� Caregiver support Caregiver support

�� Caregiver training workshopsCaregiver training workshops

�� Group treatmentGroup treatment

�� Milieu training, consultation, and staff supportMilieu training, consultation, and staff support

�� Milieu interventions and initiativesMilieu interventions and initiatives

�� CommunityCommunity--based applicationsbased applications

��Importance of building an internal team to Importance of building an internal team to support integration goalssupport integration goals


Attachment: The Big PictureAttachment: The Big Picture

�� OverarchingOverarching: Develop safety and positive : Develop safety and positive

capacities within the childcapacities within the child’’s caregiving s caregiving

systemsystem

�� How?How?

�� Supporting caregiversSupporting caregivers

�� Increasing knowledge and skillsIncreasing knowledge and skills

�� Creating positive relationshipsCreating positive relationships

�� Increasing predictabilityIncreasing predictability

SelfSelf--Regulation: The Big PictureRegulation: The Big Picture

�� OverarchingOverarching: Increase child/adolescent capacity : Increase child/adolescent capacity to manage emotional and physiological to manage emotional and physiological experienceexperience

�� How?How?�� Build a language for emotions, energy, and body Build a language for emotions, energy, and body

statesstates

�� Build capacity to recognize these states in self and Build capacity to recognize these states in self and otherother

�� Explore and support use of tools (individual as well as Explore and support use of tools (individual as well as external and systemic) to better manage experienceexternal and systemic) to better manage experience

�� Increase communication resources, and capacities to Increase communication resources, and capacities to use those resources effectivelyuse those resources effectively


Competency: The Big PictureCompetency: The Big Picture

�� OverarchingOverarching: Support key reflective capacities, : Support key reflective capacities,

including ability to make active choices and including ability to make active choices and

sense of selfsense of self

�� How?How?

�� Notice choices, assist with problemNotice choices, assist with problem--solving, link solving, link

actions and outcomes, and reflect on causeactions and outcomes, and reflect on cause--andand--

effecteffect

�� Tune in (and support child in tuning in) to attributes, Tune in (and support child in tuning in) to attributes,

experiences, values, goals, opinions, etc.experiences, values, goals, opinions, etc.

�� Pay attention to the range of areas in which a child Pay attention to the range of areas in which a child

may build developmental masterymay build developmental mastery

Trauma Experience Integration: Trauma Experience Integration:

The Big PictureThe Big Picture

�� OverarchingOverarching: Support self: Support self--reflective reflective capacities, and ability to understand the capacities, and ability to understand the self and act in the self and act in the presentpresent, while taking , while taking into account the context of the past.into account the context of the past.

�� How?How?�� Doing all of those things weDoing all of those things we’’ve just talked ve just talked

aboutabout……..the integration of many different ..the integration of many different skills to manage, tolerate, explore, and skills to manage, tolerate, explore, and understand personal experience, understand personal experience, relationships, and systems of meaningrelationships, and systems of meaning


AttachmentSelf-

Regulation Competency

Trauma

Experience

Integration

Attachment

Main / Overarching Domain Concept: Build safe / trauma-informed caregivingsystems and safe relationships that support children / adolescents

Attunement: Core Target / Goal

Help caregivers to better understand children / adolescents

Key Sub-skills/Clinical Objectives:

-Build active curiosity

-Build reflective listening skills

-Use attunement skills in support of youth regulation

-Build pleasure / positive engagement

Techniques:

i.e., Dyadic check-ins, feeling charades, etc.


ATTACHMENTATTACHMENT

Caregiver Affect Mgmt.

Attunement Consistent Response

Routines and

Rituals

Caregiver Affect ManagementCaregiver Affect Management

�� The Main Idea:The Main Idea: Support the childSupport the child’’s s

caregiving system caregiving system –– whether parents or whether parents or

professionals professionals –– in understanding, in understanding,

managing, and coping with their own managing, and coping with their own

emotional responses, so that they are emotional responses, so that they are

better able to support the children in their better able to support the children in their

care.care.Caregiver

Affect

Mgmt.


Trauma CycleTrauma Cycle

The Breakfast Club: Eat my ShortsThe Breakfast Club: Eat my Shorts

An example of poor caregiver affect An example of poor caregiver affect

management.management.

The Trauma CycleThe Trauma Cycle

““I have to up the ante or I have to up the ante or

this family will never do this family will never do

the right thing.the right thing.””

Reactivity, control, Reactivity, control,

punitive responsespunitive responses

Frustration, anger, Frustration, anger,

burnout, loss of empathyburnout, loss of empathy

I am ineffective.I am ineffective.

This family/ this parent is This family/ this parent is

so difficult. They need to so difficult. They need to

just do what I ask them to just do what I ask them to

do.do.

ProviderProvider

““He keeps fighting me; I He keeps fighting me; I

better dig my heels in.better dig my heels in.””

““This provider doesnThis provider doesn’’t get it t get it

–– II’’m not going to bother.m not going to bother.””

““II’’m being m being

controlled; I have to controlled; I have to

fight harder.fight harder.””

The CycleThe Cycle

OverOver--reacting, Controlling, reacting, Controlling,

Shutting down / Shutting down /

Disconnecting emotionally.Disconnecting emotionally.

Avoidance, Avoidance,

aggression, preaggression, pre--

emptive rejection emptive rejection

and selfand self--protection.protection.

Behavior Behavior

(Coping (Coping

Strategy)Strategy)

Frustration, Anxiety, Frustration, Anxiety,

HelplessnessHelplessnessShame, Anger, Shame, Anger,

Fear, HopelessnessFear, HopelessnessEmotionalEmotional

I am ineffective.I am ineffective.

This kid is causing trouble. This kid is causing trouble.

HeHe’’s making things chaotic s making things chaotic

for everyone.for everyone.

I am bad, unlovable, I am bad, unlovable,

damaged.damaged.

People are People are

dangerous. I candangerous. I can’’t t

trust anyone.trust anyone.

CognitiveCognitive

Caregiver / StaffCaregiver / StaffYouthYouth


A1 A1 –– How do we increase our How do we increase our

ability to regulate? Primary Targetsability to regulate? Primary Targets

(1) Validation, (1) Validation, psychoeducationpsychoeducation and depersonalizationand depersonalization�� Normalizing caregiver responses and depersonalizing youth Normalizing caregiver responses and depersonalizing youth

behaviors / reactionsbehaviors / reactions

(2) Identifying difficult situations(2) Identifying difficult situations�� Building awareness of challenging situationsBuilding awareness of challenging situations

(3) Self(3) Self--monitoring skillsmonitoring skills�� Increasing capacity to Increasing capacity to ““tune intune in”” to our own reactionsto our own reactions

(4) Self(4) Self--care and supportcare and support�� Building coping strategies and support systems that facilitate Building coping strategies and support systems that facilitate

caregiver selfcaregiver self--carecare

AttunementAttunement

�� The Main Idea:The Main Idea: Support the childSupport the child’’s s

caregiving system caregiving system –– whether parents or whether parents or

professionals professionals –– in learning to accurately in learning to accurately

and empathically understand and respond and empathically understand and respond

to childrento children’’s actions, communications, s actions, communications,

needs, and feelings.needs, and feelings.

Attunement


A2 A2 -- Attunement: Key ConceptsAttunement: Key Concepts�� Children often communicate emotions and internal experience via Children often communicate emotions and internal experience via

behavior, rather than words; traumatized children, in particularbehavior, rather than words; traumatized children, in particular, may , may lack the capacity to communicate their needs or even to know whalack the capacity to communicate their needs or even to know what t those needs arethose needs are

�� Difficult behaviors are often fronts for unmet needs or unregulaDifficult behaviors are often fronts for unmet needs or unregulated ted affect; affect; a key attunement challenge is therefore to identify the functiona key attunement challenge is therefore to identify the functionof youth behaviorof youth behavior

�� Attunement is an ongoing process, and involves Attunement is an ongoing process, and involves perceptionperception as well as as well as responseresponse

�� Accurate attunement in the caregiving system provides the foundaAccurate attunement in the caregiving system provides the foundation tion for youth selffor youth self--regulation; link these explicitly. The more the system is regulation; link these explicitly. The more the system is ACTIVE in its attunement efforts, the more reflective this proceACTIVE in its attunement efforts, the more reflective this process will ss will be (and the less reactive!)be (and the less reactive!)

Consistent

Response

Consistent ResponseConsistent Response

�� The Main Idea:The Main Idea: Support the caregiving Support the caregiving

system, whether familial or programmatic, system, whether familial or programmatic,

in building predictable, safe, and in building predictable, safe, and

appropriate responses to childrenappropriate responses to children’’s s

behaviors, in a manner that acknowledges behaviors, in a manner that acknowledges

and is sensitive to the role of past and is sensitive to the role of past

experiences in current behaviors.experiences in current behaviors.


An alternative approach: An alternative approach:

Two primary goalsTwo primary goals

�� (1) Incorporate the system(1) Incorporate the system’’s s understanding understanding of of

youth behavior into their youth behavior into their response toresponse to the the

behavior (i.e., incorporate attunement into youth behavior (i.e., incorporate attunement into youth

management strategies, ideally reducing the management strategies, ideally reducing the

need for limits)need for limits)

�� (2) Build responses to behavior that are (2) Build responses to behavior that are

consistent, appropriate, and sensitive to trauma consistent, appropriate, and sensitive to trauma

influences on youth responses (i.e., building influences on youth responses (i.e., building

consistent responses that consistent responses that increaseincrease, rather than , rather than

decreasedecrease, felt safety), felt safety)

Building Consistent ResponseBuilding Consistent Response

�� Support caregivers in understanding their own Support caregivers in understanding their own emotional / physiological / cognitive / behavioral emotional / physiological / cognitive / behavioral responses in the face of child behaviorsresponses in the face of child behaviors

�� Support attunement efforts: what is the function Support attunement efforts: what is the function of the childof the child’’s behavior? Is this a regulation s behavior? Is this a regulation moment, or a limitmoment, or a limit--setting moment? (Or both?)setting moment? (Or both?)

�� Provide support, education, and coaching in Provide support, education, and coaching in parenting strategies, as needed. Build slowly. parenting strategies, as needed. Build slowly. Explore the caregiverExplore the caregiver’’s personal / cultural beliefs s personal / cultural beliefs about appropriate parenting and their own about appropriate parenting and their own historical parenting experiences.historical parenting experiences.


Building Consistent ResponseBuilding Consistent Response

�� Actively engage youth in setting / defining / Actively engage youth in setting / defining / understanding household / milieu / understanding household / milieu / contextual rules, as appropriatecontextual rules, as appropriate

�� Explore values underlying rules, and find Explore values underlying rules, and find common groundcommon ground

�� Solicit youth input on ways adults can Solicit youth input on ways adults can support them in following established support them in following established structures; anticipate / collaborate on structures; anticipate / collaborate on building successbuilding success

Routines and RitualsRoutines and Rituals

�� The Main Idea:The Main Idea: Build predictability through Build predictability through

use of individual, familial, and systemic use of individual, familial, and systemic

routines and rituals.routines and rituals.

Routines

and

Rituals


A4 A4 –– The role of routines: The role of routines:

Key ConceptsKey Concepts�� Trauma is often associated with chaos and loss of Trauma is often associated with chaos and loss of

control; predictability helps build feelings of safety in control; predictability helps build feelings of safety in traumatized childrentraumatized children

�� When children feel safe, they are able to shift their When children feel safe, they are able to shift their energy from survival to healthy developmentenergy from survival to healthy development

�� Repetition is an important way that children gain skill; Repetition is an important way that children gain skill; children often notice routines more in their absence than children often notice routines more in their absence than in their presencein their presence

�� Routines should be part of the daily fabric, as well as Routines should be part of the daily fabric, as well as targeting areas of vulnerability or difficultytargeting areas of vulnerability or difficulty

A4 A4 –– The role of ritual: The role of ritual:

Key ConceptsKey Concepts�� RitualsRituals (traditions, celebrations, patterns of experience) (traditions, celebrations, patterns of experience)

offer felt coherence among members of a family, culture, offer felt coherence among members of a family, culture, or community, and may repeat across generationsor community, and may repeat across generations

�� Shared rituals may provide a sense of belonging; feeling Shared rituals may provide a sense of belonging; feeling disconnected from dominant culture rituals may highlight disconnected from dominant culture rituals may highlight a feeling of differencea feeling of difference

�� Exploration and celebration of ritual may include both Exploration and celebration of ritual may include both establishment and celebration of establishment and celebration of wholewhole--systemsystem rituals, rituals, as well as exploration, sharing, and celebration of many as well as exploration, sharing, and celebration of many individual ritualsindividual rituals


Domain 2:Domain 2:

SELFSELF--REGULATIONREGULATION

Affect Identification

ModulationAffect

Expression

Affect

Identification

Affect Identification:Affect Identification:

�� The Main Idea:The Main Idea: Work with children to build an Work with children to build an

awareness of internal experience, the ability to awareness of internal experience, the ability to

discriminate and name emotional states, and an discriminate and name emotional states, and an

understanding of where these states come from.understanding of where these states come from.


ConsiderationsConsiderations

�� Pair attunement with affect identificationPair attunement with affect identification:Caregiver attunement :Caregiver attunement skills can be used to support the child in affect identificationskills can be used to support the child in affect identification. . Consider doing the work simultaneously.Consider doing the work simultaneously.

�� Be mindful of cultural influencesBe mindful of cultural influences: Culture and context impact our : Culture and context impact our language for emotion, as well as our experience of it. Be cautilanguage for emotion, as well as our experience of it. Be cautious of ous of making assumptions.making assumptions.

�� Use your own imagination and creativityUse your own imagination and creativity to create feelingsto create feelings--relevant activities.relevant activities.

�� Work with all caregiversWork with all caregivers to incorporate basic feelings identification to incorporate basic feelings identification into their own interactions with the child.into their own interactions with the child.

�� Choose your momentsChoose your moments: Much of this work happens in the : Much of this work happens in the moment, and in conversation. Tune into opportunities to exploremoment, and in conversation. Tune into opportunities to exploreaffect in the material children are already bringing in.affect in the material children are already bringing in.

Affect Identification Affect Identification -- BasicBasic


Affect Identification Affect Identification -- BasicBasic

Affect

Modulation

ModulationModulation

�� The Main Idea:The Main Idea: Work with children to develop Work with children to develop

safe and effective strategies to manage and safe and effective strategies to manage and

regulate physiological and emotional regulate physiological and emotional

experience, in service of maintaining a experience, in service of maintaining a

comfortable state of arousal.comfortable state of arousal.


ModulationModulation

Little Girl Throwing a TantrumLittle Girl Throwing a Tantrum

R2 R2 -- ModulationModulationModulation Involves Multiple SkillsModulation Involves Multiple Skills::

�� Ability to identify initial emotional/physiological stateAbility to identify initial emotional/physiological state

�� Ability to identify and Ability to identify and connectconnect to subtle changes in state. to subtle changes in state. A note about A note about connectionconnection: This is the ability to : This is the ability to tune intotune into, , toleratetolerate, and , and sustainsustain connection to connection to emotional/physiological states. emotional/physiological states.

�� Ability to identify what it Ability to identify what it feelsfeels like in the body to like in the body to experience subtle changes in stateexperience subtle changes in state

�� Ability to identify and use strategies to manage those Ability to identify and use strategies to manage those state changesstate changes


R2 R2 -- ModulationModulationSpecific Targets / SkillsSpecific Targets / Skills: :

�� Build understanding of Build understanding of comfortablecomfortable and and effectiveeffective states states

�� Build an understanding of degrees of feelings and Build an understanding of degrees of feelings and energyenergy

�� Support children in exploring arousal states, and in Support children in exploring arousal states, and in developing a sense of agency over tools that allow them developing a sense of agency over tools that allow them to manage emotions and energy (build a to manage emotions and energy (build a ““feelings feelings toolboxtoolbox””). ).

�� Support and facilitate strategies which effectively and Support and facilitate strategies which effectively and comfortably lead to state changescomfortably lead to state changes

Modulation: Safe PlaceModulation: Safe Place


Affect Expression:Affect Expression:

�� The Main Idea:The Main Idea: Help children build the Help children build the

skills and tolerance for effectively sharing skills and tolerance for effectively sharing

emotional experience with othersemotional experience with others

Affect

Expression

R3 R3 –– Key Skills and TargetsKey Skills and Targets

�� Exploration of the goals of expression; Exploration of the goals of expression; build comfort and safety in relationshipbuild comfort and safety in relationship

�� Identifying resources for safe expressionIdentifying resources for safe expression

�� Effectively using resourcesEffectively using resources�� Initiating communicationInitiating communication

�� Effective nonverbal communication skillsEffective nonverbal communication skills

�� Effective verbal communication skillsEffective verbal communication skills

�� Building and supporting forums for selfBuilding and supporting forums for self--expressionexpression


Domain 3: CompetencyDomain 3: Competency

Dev’tal Tasks

Executive

FunctionsSelf Dev’t

& Identity

Developmental CompetenciesDevelopmental Competencies

�� Each developmental stage builds on the learning and Each developmental stage builds on the learning and experience of the previous stageexperience of the previous stage

�� Competency and mastery of tasks at each stage lead to Competency and mastery of tasks at each stage lead to construction of an internal sense of construction of an internal sense of efficacyefficacy and and achievementachievement; in turn, this increases confidence in ; in turn, this increases confidence in approaching new tasksapproaching new tasks

�� When children are exposed to chronic trauma, energy When children are exposed to chronic trauma, energy that is normally invested into development of that is normally invested into development of competencies is instead invested in survivalcompetencies is instead invested in survival


Executive FunctionsExecutive Functions

�� The Main Idea:The Main Idea: Work with children to act, Work with children to act,

instead of react, by using higherinstead of react, by using higher--order order

cognitive processes to solve problems and cognitive processes to solve problems and

make active choices in service of reaching make active choices in service of reaching

identified goalsidentified goals

Executive

Functions

Self and IdentitySelf and Identity

�� The Main Idea:The Main Idea: Support children in Support children in

exploring and building an understanding of exploring and building an understanding of

self and personal identity, including self and personal identity, including

identification of unique and positive identification of unique and positive

qualities, building of coherence across qualities, building of coherence across

time and experience, and support in the time and experience, and support in the

capacity to imagine and work toward a capacity to imagine and work toward a

range of future possibilitiesrange of future possibilities

Self Dev’t

& Identity


ConsiderationsConsiderations

�� Consider group as well as individual identity goals for all Consider group as well as individual identity goals for all domains; i.e.:domains; i.e.:�� Unique self:Unique self:

•• What characteristics does each child contribute?What characteristics does each child contribute?

•• What makes this setting unique? (Group values, goals, etc.)What makes this setting unique? (Group values, goals, etc.)

�� Positive self:Positive self:•• Support and reinforce child successesSupport and reinforce child successes

•• Establish community pride; set collaborative group goalsEstablish community pride; set collaborative group goals

�� Coherent self:Coherent self:•• Notice and normalize differences in child presentation and Notice and normalize differences in child presentation and

experience across moments and settingexperience across moments and setting

•• Notice coherence and fragmentation among group membersNotice coherence and fragmentation among group members

�� Future self:Future self:•• Support individual youth in setting and working toward future goSupport individual youth in setting and working toward future goalsals

•• Set programmatic / community goals, and support members of the Set programmatic / community goals, and support members of the system in working toward thesesystem in working toward these

Trauma Experience IntegrationTrauma Experience Integration

The Main Idea: The Main Idea: Work with children to actively Work with children to actively

explore, process, and integrate historical explore, process, and integrate historical

experiences into a coherent and comprehensive experiences into a coherent and comprehensive

understanding of self in order to enhance understanding of self in order to enhance

childrenchildren’’s capacity to effectively engage in s capacity to effectively engage in

present life.present life.

Trauma

Experience

Integration

The Main Idea: The Main Idea: Work with children to actively Work with children to actively

explore, process, and integrate historical explore, process, and integrate historical

experiences into a coherent and comprehensive experiences into a coherent and comprehensive

understanding of self understanding of self in order toin order to enhance enhance

childrenchildren’’s capacity to effectively engage in s capacity to effectively engage in

present lifepresent life..


Children are not simply a composite of their Children are not simply a composite of their

deficits, but are whole beings, with deficits, but are whole beings, with

strengths, vulnerabilities, challenges, and strengths, vulnerabilities, challenges, and

resources.resources.

ARC provides a framework that seeks to ARC provides a framework that seeks to

recognize factors that derail normative recognize factors that derail normative

development, and to work with children, development, and to work with children,

families, and systems to build or refamilies, and systems to build or re--build build

healthy developmental pathways.healthy developmental pathways.

Sensory Motor Arousal Sensory Motor Arousal

Regulation Therapy Regulation Therapy

(SMART)(SMART)


The Modulation ModelThe Modulation Model©©

High ActivationHigh Activation

with Permission of the Sensorimotor Psychotherapy Institute, © Ogden and Minton (2000)

A

RO

US

AL

A

RO

US

AL

Hyperarousal

Hyper-defensive

Emotional reactivity

Hypoarousal

Disabled defensives responses

Numbing

“inside our Window of Tolerance”

(D. Siegel 1999)

Optimal Arousal ZoneOptimal Arousal ZoneOptimal Arousal Zone

Hypervigilant

Intrusive images

Obsessive/Cyclical Cognitive Processing

Low ActivationLow Activation Collapsed

Flat Affective

Cognitively Disabled

Extreme Stress:Extreme Stress:Extreme Stress:Extreme Stress: Triggered to fight / flee, out of control fear or rage / Triggered to fight / flee, out of control fear or rage / Triggered to fight / flee, out of control fear or rage / Triggered to fight / flee, out of control fear or rage / ““““PanickyPanickyPanickyPanicky”…”…”…”….. .. .. ..

Going to Going to Going to Going to ““““jump out of my skinjump out of my skinjump out of my skinjump out of my skin”””” / Coping resources really hard to engage, alone / / Coping resources really hard to engage, alone / / Coping resources really hard to engage, alone / / Coping resources really hard to engage, alone / Enraged and out of control / Enraged and out of control / Enraged and out of control / Enraged and out of control / ““““IIII’’’’ve got to get out of hereve got to get out of hereve got to get out of hereve got to get out of here””””

Extreme Stress:Extreme Stress:Extreme Stress:Extreme Stress: Triggered to engage automatic survival responses of freezing, Triggered to engage automatic survival responses of freezing, Triggered to engage automatic survival responses of freezing, Triggered to engage automatic survival responses of freezing,

numbing/ Not feeling numbing/ Not feeling numbing/ Not feeling numbing/ Not feeling ““““herehereherehere””””, not feeling , not feeling , not feeling , not feeling ““““memememe”””” / Coping resources are really hard to / Coping resources are really hard to / Coping resources are really hard to / Coping resources are really hard to engage alone / Really low energy, doesnengage alone / Really low energy, doesnengage alone / Really low energy, doesnengage alone / Really low energy, doesn’’’’t seem really present.t seem really present.t seem really present.t seem really present.

CONTAINED, CALM, ALERT,CONTAINED, CALM, ALERT,CONTAINED, CALM, ALERT,CONTAINED, CALM, ALERT,

FEELS PRESENT / FEELS SAFEFEELS PRESENT / FEELS SAFEFEELS PRESENT / FEELS SAFEFEELS PRESENT / FEELS SAFE

Adapted from Candace Saunders, LICSW and based on Pat Ogden’s “Windows of Tolerance”, Trauma and the Body

Increased Stress: More Increased Stress: More Increased Stress: More Increased Stress: More ““““Reactively ACTIVEReactively ACTIVEReactively ACTIVEReactively ACTIVE””””,,,, agitated, anxious, angry but able to agitated, anxious, angry but able to agitated, anxious, angry but able to agitated, anxious, angry but able to control self and control self and control self and control self and ““““be presentbe presentbe presentbe present””””

Increased Stress: More Increased Stress: More Increased Stress: More Increased Stress: More ““““Reactively INACTIVEReactively INACTIVEReactively INACTIVEReactively INACTIVE””””,,,, depressed, spacey, but able to depressed, spacey, but able to depressed, spacey, but able to depressed, spacey, but able to control self and control self and control self and control self and ““““be presentbe presentbe presentbe present””””


Sensory Motor Arousal Regulation Sensory Motor Arousal Regulation

Training (SMART)Training (SMART)

SMARTSMART

Self-Regulation through 3 types of input:•• Vestibular input:Vestibular input: the kid who lies on the the kid who lies on the couch upside down.couch upside down.

•• ProprioceptiveProprioceptive input:input: the kid who is the kid who is roughhousing with others, or jumping roughhousing with others, or jumping around.around.

•• Tactile input:Tactile input: the kid who seems to seek the kid who seems to seek restraints, or needs lots of stuff on him to restraints, or needs lots of stuff on him to sleepsleep


Why SMART for trauma?Why SMART for trauma?

A treatment aimed at A treatment aimed at subcorticalsubcortical as well asas well as

cortical systems:cortical systems:..

�� Begins with movement and sensation, exploration and Begins with movement and sensation, exploration and

curiosity as routes to better regulation.curiosity as routes to better regulation.

�� Does not rely on language as entry point.Does not rely on language as entry point.

�� Allows integration of affect through Allows integration of affect through engagement of the engagement of the whole body.whole body.

�� Cognitive understanding or a coherent narrative emerges Cognitive understanding or a coherent narrative emerges

as the consequence of full engagement of the as the consequence of full engagement of the subcorticalsubcortical

systems (sensory, motor, limbic/emotional, and autonomic systems (sensory, motor, limbic/emotional, and autonomic

arousal).arousal).

�� Uses present moment new experience to expand and Uses present moment new experience to expand and

create new capacity for attachment through cocreate new capacity for attachment through co-- and selfand self--

regulation.regulation.

NeurofeedbackNeurofeedback (NFB)(NFB)


State of Arousal and EEG Wave PatternsState of Arousal and EEG Wave Patterns

NeurofeedbackNeurofeedback (NFB)(NFB)�� EGG biofeedback.EGG biofeedback.

�� Brain activity measured and Brain activity measured and interpreted by the computer.interpreted by the computer.

�� Visual and auditory feedback Visual and auditory feedback in form of simple computer in form of simple computer games.games.

�� Uses operant conditioning to Uses operant conditioning to ““train the braintrain the brain”” to perform at to perform at an optimal level.an optimal level.

�� ““Top downTop down”” approach to approach to quiet the brain and body.quiet the brain and body.

�� Shown to improve attention, Shown to improve attention, concentration, selfconcentration, self--regulation regulation and depression, as well as and depression, as well as reduce irritability and anger.reduce irritability and anger.


NFB Trauma ProtocolNFB Trauma Protocol

�� T4T4--P4 placement.P4 placement.

�� Training focused on Training focused on inhibiting slow wave inhibiting slow wave (Delta and Theta) and (Delta and Theta) and high wave (High Beta) high wave (High Beta) activity, while rewarding activity, while rewarding Alpha activity.Alpha activity.

�� Protocol designed to Protocol designed to increase selfincrease self--regulation regulation and reduce and reduce hypersensitivity to stimuli.hypersensitivity to stimuli.

Case ExampleCase Example


Case Example: Case Example: ““KatieKatie””�� 16 year old adopted, African American female.16 year old adopted, African American female.

�� Treatment at VDK for 8 months.Treatment at VDK for 8 months.

�� Incoming Diagnoses: Reactive Attachment Disorder, Incoming Diagnoses: Reactive Attachment Disorder, Bipolar, PTSD, ADHD, ODD, R/O Borderline IQ.Bipolar, PTSD, ADHD, ODD, R/O Borderline IQ.

�� Presentation at intake:Presentation at intake:�� High levels of High levels of dysregulationdysregulation and reactivity.and reactivity.�� Regressive, Regressive, ““primitiveprimitive”” and selfand self--harm behaviors when harm behaviors when

dysregulateddysregulated..�� Easily overwhelmed, leading to becoming shut down.Easily overwhelmed, leading to becoming shut down.�� Needed almost constant attention from adults.Needed almost constant attention from adults.�� Developmentally immature (i.e. childlike) interpersonal Developmentally immature (i.e. childlike) interpersonal

interactions.interactions.�� Active PTSD symptoms.Active PTSD symptoms.�� Angered easily, often perceived hostile intent from others.Angered easily, often perceived hostile intent from others.�� Negative self concept.Negative self concept.�� Limited ability to engage in school.Limited ability to engage in school.�� Difficulty making friends.Difficulty making friends.

Individual ContextIndividual Context

Severe and chronic neglect by parents.Severe and chronic neglect by parents.

Physical and sexual abuse by father.Physical and sexual abuse by father.

Sexual exploitation by father.Sexual exploitation by father.

Severe emotional and behavioralSevere emotional and behavioral

difficulties (sleep difficulties, aggression, difficulties (sleep difficulties, aggression, hyperactivity, oppositional & hyperactivity, oppositional & sexualized behaviors).sexualized behaviors).

Supervised visit with father where she Supervised visit with father where she ““went limp and blank.went limp and blank.””

Symptoms Symptoms –– impulsivity, aggression, impulsivity, aggression, defiance, nightmares, flashbacks, defiance, nightmares, flashbacks, avoidance, etc., etc.avoidance, etc., etc.

Severe attachment difficulties.Severe attachment difficulties.

Dissociative response Dissociative response –– ““space out or go space out or go to sleep when stressed.to sleep when stressed.””

Multiple instances of running away. Multiple instances of running away.

Sexual assault by unknown male in the Sexual assault by unknown male in the community.community.

Reemergence of memories of early Reemergence of memories of early sexual and physical abuse by father.sexual and physical abuse by father.

Self harm behaviors increase in Self harm behaviors increase in frequency and severity.frequency and severity.

Serious suicide attempt.Serious suicide attempt.

Environmental ContextEnvironmental Context

Bio mom: severe and persistent Bio mom: severe and persistent mental illness.mental illness.

Exposure to domestic violence.Exposure to domestic violence.

Father leaves family.Father leaves family.

NonNon--compliance with mental health compliance with mental health services for Katie.services for Katie.

Removed from motherRemoved from mother’’s care.s care.

8 placements, including first 8 placements, including first psychiatric hospitalization.psychiatric hospitalization.

Adopted by current family.Adopted by current family.

Multiple transitions between schools.Multiple transitions between schools.

Good motivation and ability in school if Good motivation and ability in school if highly structured.highly structured.

Estimated 15Estimated 15--20 psychiatric 20 psychiatric hospitalizations. hospitalizations.

3 stays in residential treatment.3 stays in residential treatment.

Birth - 4

3-5

Age

6-12

12-16


““Medical Model/Diagnostic LensMedical Model/Diagnostic Lens””

AssumptionsAssumptions

�� Bipolar: Chemical imbalance in the brain.Bipolar: Chemical imbalance in the brain.

�� ADHD: Dysfunctional frontal lobe leading to poor ADHD: Dysfunctional frontal lobe leading to poor inhibition.inhibition.

�� RAD: RAD: �� Unable to love or feel empathy for others.Unable to love or feel empathy for others.

�� Behavior driven by need to control and manipulate.Behavior driven by need to control and manipulate.

�� Borderline IQ: Cognitively impaired, limited Borderline IQ: Cognitively impaired, limited ability to learn.ability to learn.

�� Conduct/Oppositional Behaviors: aggression, Conduct/Oppositional Behaviors: aggression, defiance, and inability to follow directives.defiance, and inability to follow directives.

““Trauma LensTrauma Lens””Complex PTSD/Developmental Trauma Disorder Framework:Complex PTSD/Developmental Trauma Disorder Framework:

�� SelfSelf--regulation is impaired: regulation is impaired: �� Highly Highly dysregulateddysregulated and impulsive. and impulsive. �� Frequent and severe self harm and regressive behaviors.Frequent and severe self harm and regressive behaviors.

�� Dissociative coping response: Dissociative coping response: �� ““State dependentState dependent”” presentation shown by vacillation between periods of presentation shown by vacillation between periods of

stability and extreme instability.stability and extreme instability.

�� Low SelfLow Self--Esteem:Esteem:�� Persistent negative sense of self.Persistent negative sense of self.�� Feelings of depression and hopelessness.Feelings of depression and hopelessness.

�� Disorganized attachment style.Disorganized attachment style.�� Push/pull in interpersonal relationships.Push/pull in interpersonal relationships.�� Poor social skills.Poor social skills.

�� Limbic system Limbic system highjackshighjacks the the neocortexneocortex::�� Executive functioning deficits.Executive functioning deficits.�� Poor attention and concentration.Poor attention and concentration.

�� Worldview shaped by early environment:Worldview shaped by early environment:�� Hostile attribution bias.Hostile attribution bias.�� Preoccupation with threat (i.e. Preoccupation with threat (i.e. hypervigilencehypervigilence).).


CORE Battery MeasuresCORE Battery Measures�� UCLA PTSD Reaction IndexUCLA PTSD Reaction Index (Steinberg, (Steinberg, BrymerBrymer, Decker, , Decker, PynoosPynoos, ,

2004):2004):

�� Exposure to traumatic events (baseline only).Exposure to traumatic events (baseline only).�� PTSD Symptoms:PTSD Symptoms:

•• Intrusive: flashbacks, nightmares, intrusive thoughts.Intrusive: flashbacks, nightmares, intrusive thoughts.

•• Avoidance: cognitive and/or behavioral avoidance.Avoidance: cognitive and/or behavioral avoidance.

•• Arousal: Arousal: hyperarousalhyperarousal, sleep difficulties., sleep difficulties.

�� NovacoNovaco Anger Scale and Provocation InventoryAnger Scale and Provocation Inventory (NAS(NAS--PI; PI; NovacoNovaco, 2003):, 2003):�� Cognitive: anger justification, rumination, hostility, and suspiCognitive: anger justification, rumination, hostility, and suspicion.cion.

�� Arousal: Anger intensity, duration, somatic tension, and irritabArousal: Anger intensity, duration, somatic tension, and irritability.ility.

�� Behavior: Impulsive reaction, verbal aggression, physical confroBehavior: Impulsive reaction, verbal aggression, physical confrontation, and ntation, and indirect expression. indirect expression.

�� Anger regulation.Anger regulation.�� Provocation: sensitivity to disrespectful treatment, unfairness,Provocation: sensitivity to disrespectful treatment, unfairness, frustration, frustration,

annoying traits of others, and irritations annoying traits of others, and irritations

�� Child Behavior ChecklistChild Behavior Checklist (CBCL; Achenbach & (CBCL; Achenbach & RescorlaRescorla, 2001):, 2001):

�� Internalizing symptoms.Internalizing symptoms.�� Externalizing symptoms.Externalizing symptoms.

CBCL at IntakeCBCL at Intake

0

10

20

30

40

50

60

70

80

90

100

Anx

/Dep

With

drwn/

Dep

Som

atic

Socia

l

Thou

ght

Atte

ntion

Rule

-Brk

ing

Agg

ress

ive

Inte

rnaliz

ing

Exter

naliz

ing

CB

CL

T-S

co

re


NASNAS--PI at IntakePI at Intake

0

1020

30

40

5060

70

80

Cogn

itive

Aro

usal

Beh

avior

NAS T

otal

Pro

voca

tion In

vent

ory

Ang

er R

egula

tion

NA

S-P

I T

-Sco

re

PTSD Reaction Index at IntakePTSD Reaction Index at Intake

0

10

20

30

40

50

60

70

Total Score Crit. B:

Reexperiencing

Crit. C:

Avoidance

Crit. D:

Hyperarousal

PT

SD

-RI

Sc

ore


Systemic

Familial

Individual

ATTACHMENT

•Caregiver affect management

•Attunement

•Consistent response

•Routines and Rituals

REGULATION

•Affect Identification

•Modulation

•Affect Expression

COMPETENCY

Primary Components

•Executive functions

•Self development

ARCARC: :

A Framework A Framework

For For

Intervention Intervention

with with

Complexly Complexly

Traumatized Traumatized

YouthYouth

Blaustein & Kinniburgh, 2010;

Kinniburgh & Blaustein, 2005

TRAUMA EXPERIENCE

INTEGRATION

ARC ApproachARC Approach

�� SelfSelf--Regulation:Regulation:�� NeurofeedbackNeurofeedback (NFB): (NFB): ““Top downTop down”” regulation.regulation.�� Sensory Motor Arousal Regulation Therapy (SMART): Sensory Motor Arousal Regulation Therapy (SMART): ““Bottom Bottom

upup”” regulation.regulation.�� Integration of sensory motor tools in the milieu and school Integration of sensory motor tools in the milieu and school

contexts.contexts.�� Individualized planning in milieu to encourage translation of seIndividualized planning in milieu to encourage translation of selflf--

regulation skills (ex. settling plan) in day to day.regulation skills (ex. settling plan) in day to day.

�� Attachment:Attachment:�� SMART: Build attachment with individual therapist.SMART: Build attachment with individual therapist.�� Milieu interventions focused on building positive relationships Milieu interventions focused on building positive relationships

(Ed and Res advocates) and getting needs for nurturance and (Ed and Res advocates) and getting needs for nurturance and affection met in a positive way (ex. hug plan). affection met in a positive way (ex. hug plan).

�� Focus on routines, rituals, consistent responding and caregiver Focus on routines, rituals, consistent responding and caregiver affect management across the board.affect management across the board.


SMART SessionSMART Session

Restraint DataRestraint Data

0

1

2

3

4

5

6

1 2 3 4 5 6 7 8

Month

Nu

mb

er

of

Restr

ain

ts


PTSD Symptom ChangePTSD Symptom Change

0

10

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30

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50

60

70

Total S

core

Crit

. B: R

eexp

erie

ncin

g

Crit

. C: A

void

ance

Crit

. D: H

yper

arou

sal

PT

SD

-RI

Sc

ore

Intake

3 Months

Discharge

CBCL Symptom ChangeCBCL Symptom Change

**

* *

0

10

20

30

40

50

60

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90

100

Anx

/Dep

With

drwn/Dep

Som

atic

Soc

ial

Thoug

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Atte

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Rule-

Brkin

g

Agg

ress

ive

Inte

rnalizing

Exter

naliz

ing

CB

CL

T-S

co

re

Intake

3 Months

Discharge

* Indicates clinically significant improvement.


NASNAS--PI Symptom ChangePI Symptom Change

0

1020

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Cogn

itive

Aro

usal

Beh

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NAS T

otal

Pro

voca

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vent

ory

Ang

er R

egula

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NA

S-P

I T

-Sco

re

Intake

3 Months

Discharge

Treatment SummaryTreatment Summary

�� Treatment approach was individualized and integrated Treatment approach was individualized and integrated across contexts.across contexts.

�� Initial focus on building selfInitial focus on building self--regulation skills through both regulation skills through both ““top downtop down”” and and ““bottom upbottom up”” approaches (SMART, NFB).approaches (SMART, NFB).

�� Attachments across the program and with family played Attachments across the program and with family played in integral role.in integral role.

�� Underlying capacity was revealed once extreme Underlying capacity was revealed once extreme dysregulationdysregulation had stabilized.had stabilized.

�� Significant clinical improvement in PTSD, somatic, and Significant clinical improvement in PTSD, somatic, and externalizing symptoms over 8 months.externalizing symptoms over 8 months.

�� Competency piece of ARC has continued beyond Competency piece of ARC has continued beyond residential treatment residential treatment –– such as returning to her parentsuch as returning to her parent’’s s home to live, getting her drivers license, etc.home to live, getting her drivers license, etc.

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