Re-Attaching the Brain:A Developmental Treatment Approach

forTreating Sexual Behavior Problems

in Children and Adolescents

Kevin Creeden, M.A., LMHCWhitney AcademyEast Freetown, MAkcreeden@whitneyacademy .org

A Developmental Framework

•Development happens across a variety of areas: neurological, physical, emotional, social, cognitive, academic, moral, etc.

•Development proceeds from the existing competencies

Developmental Framework

•A variety of developmental models can be used in conceptualizing effective treatment

•Maslow (1968), Bowlby (1973) Strayhorn (1988), Erickson (1963)

•Common developmental issues

Common issues

•Sense of belonging: trust, safety, closeness, dependence

•Differentiating self from other

•Self-regulation of physical and emotional responses: delaying gratification

•Developing cognitive skills

Common Developmental Issues

•Cognitive flexibility/adaptive problem solving

•Moral development

•Empathy

•Creativity

Clinical Assumptions

Trauma in early childhood has a neuro-developmental impact

The individual’s own trauma experiences and their current behavior are linked through a variety of trauma associations and cues

Without addressing trauma associated symptoms the integration of new learning and new narratives will not effectively occur

There is a physiological response to trauma cues that effects processing, cognitions, emotional response, and behavioral response

It is impossible to discuss trauma in children without addressing the quality of parental attachment (van derKolk, 2003)

Engaging in abusive behavior is primarily focused on meeting relational needs

Safety is the primary goal

Competency in relationships and developmental tasks are key protective factors

Children do well if they can

Kids Have to Think That You Care Before They Care What You Think

Resiliency Factors

1. Positive attachment to emotionally supportive and competent adults

2. Development of self-regulation and cognitive abilities

3. Positive self-concept

4. Motivation to act effectively

Brain Development and Trauma

Brain abnormalities are associated with childhood abuse and neglect

(Teicher, 2002; DeBellis, 2001)

Hypothalamus: controls appetite, hormones, and sexual behavior

Amygdala:responsible for anxiety, fear and emotions

Neocortex: Site of higher cognitive functions and sensory integration

Cerebellum: seat of motor control and coordination

Hippocampus: crucial to memory and learning facts

Brain stem: responsible for sensory input and physiological responses

Brain Structure Function ImpairmentAmygdala fear conditioning; aggressive

behavior; triggers fight/flightIncreased arousal, impaired fear conditioning

Hippocampus Retrieval of verbal and emotional memory

Memory impairment, especially verbal memory

Left hemisphere Regulate analytical responses; mediate emotional responses; language processing

Difficulties in accurate, effective reading of situation; language processing

Corpus Collosum Communication and integration between hemispheres

Poor integration and modulation of responses to daily interactions

Cerebellar Vermis Production and release of neuro-transmitters

Problems regulating physical activity, attention, emotions

Prefrontal cortex Center for executive functions Poor organization, rigid problem solving; increased impulsivity

Assessment Issues

•Trauma symptom assessment • TSCC; TSI

•Screening for processing difficulties• SCAN:A; Bender; RCFT; WCST

•Family of origin issues and expectations of the parents, foster parents, or other caregivers• FAM:III; Stress Index for Parents of

Adolescents (SIPA); Clinical interview; TSI

•Discriminate attachment styles for the parents and child• Relationship Questionnaire

(Bartholomew and Horowitz, 1991)

•Behavior specific assessment: sexual knowledge, attitudes, cognitive distortions, focus of fantasies.

•Personality assessment to examine issues of depression, aggression, anti-social attitudes

Phase Oriented Treatment

Stabilization, including education and identification of feelings/somatic states

De-conditioning traumatic memories and responses

Restructuring traumatic personal schemes

van der Kolk, et al , 1996

Maslow’s Hierarchy of Needs

Treatment Interventions

•Stabilization, deconditioning, and establishing supportive relationships can be re-framed as “containment”

Structure

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WORKING ON TRAUMA thinking, feeling, and talking about trauma

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Structure

•Consistency and predictability in the schedule

•Consistency in expectations

•Consistency in responses

•Consistency in environment

•Use of rituals

Self-Regulation

•Active learning and practice of a variety of activities and techniques

Deep breathing and “counting to 10”Visualization and “safe place”Yoga or tai chiMusic, journaling, artDaily exerciseBrain gymBiofeedback

TransformationsSensory Stimulation

Transformation of information

Dispositional representations

Enacted behavior

Crittenden, 2005

Sensory Areas

•Proprioception•Vestibular•Auditory•Visual•Tactile•Olfactory•Gustatory

Proprioception

•Sensations derived primarily from large muscles and joints; especially during movement against resistanceCan help person feel grounded

• DEEP Pressure: often over-rides over arousal

Proprioception examples

•Weighted blankets or vests•Wall push ups•Walking•Isometric exercise•Brain gym•Exercise balls•Clay work

Vestibular

•Sensation derived from stimulation of vestibular mechanism in the inner ear

•Provides a sense of equilibrium and balance

•Contributes to a sense of one self in space“boundary issues”

Auditory

•Directly connected to vestibular•Sound, music, rhythm serves as a “pacemaker”

•Different sounds connected to mood, pace

•Consider different sounds in transition in environments like residential centers and schools

Gustatory

•Includes oral motor as well as taste

•Stimulation can help with attention, comfort, and overall organization

Tactile

•Touch, pressure, vibration, temperature, pain

•Provides sense of body image, boundaries, self

•Fundamentally connected to safety, comfort, self-soothing, attachment

General Characteristics

Calming•Mild•Rhythmic•Simple•Familiar•Consistent•Soothing•Low demand

Alerting•Strong•Fast paced•Non-rhythmic•Complex •Novel•Unpredictable•High demand

Anxiety and Agitation

•Deep breathing•Isometric exercise

•Rocking•Using weighted blanket

•Stress balls•Calming music•Chewing gum

•Rocking chairs or gliders

•Yoga•Mindfulness•Biofeedback•Rowing

Grounding Approaches

•Strong tastes•Sour candy or hot candy•Chewing gum•Ice tapping•Hot/cold shower•Pacing•Tapping•Movement: yoga, tai chi

Depression

•Weighted vest•Movement and exercise•Beanbag tapping•Warm pad•Scented lotion•Stroking/brushing

Calming techniques are often not helpful

Developmental Model

1) Self-Regulation

2) Attachment

3) Cognitive skills

4) Social Skills

5) Adaptive Living Skills

6) Healthy Sexuality

Self-regulation (2)

•Identifying triggers

•Connecting sensations w/ thoughts, feelings, behaviors

•Identifying choices

aspects of BrainWise

Attachment styles: Bartholomew

Style

Secure

Preoccupied

Avoidant

Dismissive

Self Others pos (+) pos (+)

neg (-) pos (+)

neg (-) neg (-)

pos (+) neg (-)

Domains of Impairment: Complex TraumaI. Attachment

Distrust

Social isolation

Attunement difficulties

Boundary problems

Problems with perspective taking

Cook, Spinnazzola, et al (2005)

Addressing Attunement

•Eye contact

•Thoughtful use of touch

•Mirroring

•Being “in sync”

•Listen, reflect, check

Brain Wise: The 10 Wise Ways

1. Wizard Brain over Lizard Brain

2. Constellation of Support

3. Recognize Red Flag Warnings

4. Exit the Emotions Elevator

5. Separate Fact from Opinion

Wise Ways6. Ask Questions

7. Identify Your Choices

8. Consequences: Now and Later; Affecting Others

9. Set Goals and Form a Plan

10.Communicate Effectively

6. Domain:Healthy Sexuality

Elements: Understanding Rules and Limitations of Sexual Behavior at Whitney

Interventions: Present and discuss Whitney Sexual Behavior Rules

Elements: Self-Regulation (see above)

Elements: Maintaining appropriate personal space (see above)Interventions: Kornblum: Chapter 2

Recreational therapy

Elements: Accurate Sexual InformationInterventions: Sex ed curriculum (medical)

Elements: Sexual Behavior in context of relationshipsInterventions: Sex ed curriculum (clinical)

Elements: Cognitive distortionsInterventions: BrainWise curriculum: Separate Fact from

Opinion

Elements: Role models and masculine identityInterventions: Circles curriculum

Family therapy Group therapy

•Domain: Self-Regulation

Elements: Behavior ManagementInterventions: Level System

Individual behavior management plan

Elements: Sensory IntegrationInterventions: Complete Sensory Profile

Introduce to Sensory Room Develop individualized sensory/self-regulation

tools Elements: Self-regulation skill training

Interventions: Daily stress buster exercises Use of biofeedback tools: Wild Divine; pulse

meters, etc. Dialectical Behavior therapy exercises:

(Linnehan)

Elements: Safe PlaceInterventions: Describe, write about, build, develop safe places

both real and imagined (visualization) EMDR: safe place installation (individual)

Elements: Adaptive Problem Solving SkillsInterventions: BrainWise curriculum