abc of ohio presents… attachment-focused interventions: cultivating nurturing environments to...
TRANSCRIPT
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ABC of Ohio presents…
Attachment-Focused Interventions:
Cultivating Nurturing Environments to Facilitate Parent-Child Attachment
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Part I
Theoretical Rationale:
Developmental Trauma Disorder
(Complex Trauma or Reactive Attachment Disorder)
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DEVELOPMENTAL TRAUMA DISORDER(Cook, Blaustein, Spinazzola and van der Kolk, 2003)
http://www.nctsnet.org/nctsn_assets/pdfs/edu_materials/ComplexTrauma_All.pdf
Definition
Children’s experience of multiple traumatic events that occur within the care giving system Prenatal exposure to drugs/alcohol Neglect/Institutionalization Abuse Abandonment/Multiple Moves Pain/Illness/Hospitalization
Involves simultaneous or sequential occurrences of child maltreatment—that are chronic and begin in early childhood
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Areas of Impairment
AttachmentAttachmentAffectAffect RegulationRegulationDissociationDissociationCognitionCognitionBiologyBiologyBehavioralBehavioral ControlControlSelfSelf ConceptConcept
DEVELOPMENTAL TRAUMA DISORDER(Cook, Blaustein, Spinazzola and van der Kolk, 2003)
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5
ATTACHMENT• Attachment is the process by
which an emotional connection develops between an infant and his/her caretaker
• This process organizes the infant physiologically and psychologically
• Attachment becomes the basis for how he/she will relate to the world, learn and form relationships
• In addition to the basic needs such as food, shelter and clothing, the infant needs emotional care which is essential for his/her development
• Attachment grows through daily interactions between caretaker and infant
• Smiles, nurturing touch, eye contact, mutual play build trust and security in the child
• This first relationship becomes the blueprint for all future relationships
• It is also the origin of conscience development, empathy, self-esteem and cause and effect thinking
• Insecure attachment patterns seen in 80% of maltreated children
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6
NEED
TRUST
GRATIFICATION
ANGERHIGH AROUSAL
RAGE
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DISSOCIATION• Difficulty with emotional
self-regulation• Difficulty describing feelings
and internal experience• Problems knowing and
describing internal states• Difficulty communicating
wishes and desires• Predisposed to earlier onset
of affective problems, which is associated with more episodes and poorer outcome
• Distinct alterations in states of consciousness
• Two or more distinct states of consciousness
• Hyperarousal & Dissociative• Begins as a protective
defense mechanism and then is utilized more frequently as trauma continues
AFFECT REGULATION
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Problems with…• Irrational cognitions• Sustained curiosity/initiative• Processing new information• Focusing and completing new tasks (hypervigilence vs.
hyperactivity)• Understanding own contribution to what happens to them
(cause-and-effect thinking)• Object constancy• Orientation with time and space• Learning disabilities• Abstract thinking
Cognitive
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Biology
Problems with…
• Experiences impact brain development• Lifelong reactivity to stress• Problems with coordination, balance, body tone• Somatization• Analgesia (inability to feel pain)• Hypersensitivity to physical touch• Wide variety of medical problems: pelvic pain,
asthma, skin problems, autoimmune disorders• Sensory Integration Dysfunction
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Behavioral Control
• Poor impulse control• Self destructive behavior• Aggression• Self soothing behaviors• Sleep and eating disturbances• Substance abuse• Excessive compliance or oppositional behavior• Reenactment of traumatic past
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Self Concept
• Lack of coherent sense of self
• Disturbance of body image
• Low self-esteem• Poor sense of
separateness
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7 Core IssuesThe Adoption Overlay
• Loss• Grief• Self-concept• Identity• Shame and Guilt• Intimacy and Relationships• Control
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Part II
Translating Theory into Practice:
A Tool-Box of Techniques
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Treatment Principles
Parent-Centered and
Child-Focused
Develop a Coherent Narrative
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Treatment Principles
Facilitate Grief
Shock/DenialBargainingDepression/SorrowAngerResolution
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Treatment Principles
Encourage Behavioral
Change
Encourage Emotional Regulation
(Decrease Dissociation and Hyperarousal)
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Treatment Principles
Facilitate Developmental GainsAttachmentAffect RegulationDissociationCognitiveBehavioral ControlSelf-conceptBiology
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Nurture, humor and fun!Eye contact, Touch, Talking, Smells, Food, Motion, Warmth
Treatment Principles
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A Tool-Box of Techniques
• Timeline• Life Book• Children’s Books• Journaling• Art• Role-plays
• Videos• Music• Theraplay™• Yoga• Massage
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The narrative is an emotionally rich story that makes sense of one’s life.
Affirms reality Creates meaning, provides closure, reduces need to
ruminate Organizes memories—implicit and explicit— into one
chronological account Enhances cause-and-effect, and decreases anxiety,
insecurity and confusion Reduces disparity between what the child is feeling (fear)
and current reality (safety: with parents and therapist) Reduces isolation, feeling of being unknowable and different Creates the ability to alter the child’s dysfunctional patterns
of interaction Facilitates grief which leads to developmental growth
A Tool-Box of Techniques
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Explicit or Declarative Memory We have a conscious ability to retrieve the memory
and state the facts and events. We can recall the event
Implicit or Nondeclarative Memory Implicit memory systems store emotions, sensory
experiences, and expectations and assumptions about relationships based on prior experiences
Implicit memories form early in life prior to the individual having language
They cannot be recalled but they can be triggered Briere , John and Catherine Scott (2006.) Principles of Trauma Therapy: A Guide to Symptoms, Evaluation and Treatment,
Thousand Oaks: Sage Publications.
A Tool-Box of Techniques
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“When salient experience must be unnoticed, disallowed, unacknowledged, or forgotten, the result is incoherence in the self structure. Interconnections among experiences cannot be made, and the resulting gaps in personal history compromise both the complexity and the integrity of the self”
Ogawa et al, 1997
A Tool-Box of Techniques
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23
Completely truthfuldisclosures help the
child to heal and grow
A Tool-Box of Techniques
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• Start at the beginning• Cases of Limited information• Verbal and concrete methods
• Pace- maintain emotional regulation• Value free – the child decides who to love
• Use adoption language: birth mom, birth dad, etc.• Adjust language according to child’s age:
chronological and developmental• Repeat, repeat, repeat!
A Tool-Box of TechniquesTelling the narrative “story”…
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A Tool-Box of TechniquesTelling the narrative “story”…
Anticipate questions…Say “I don’t know” as needed
“Why did my birth parents use drugs?”“Do you think my birth mom thinks about me?”“Do you think she is in jail?”“Does she have any more children?”“If they get better, can I go live with them again?”“Why didn’t anyone in my country want me?”“Why didn’t the orphanage ladies take me home?”“Do you think my orphanage friends got adopted?”“Are my birth parents alive?”“Are my siblings safe?”“Do you think my siblings think about me?”“Why did you pick me?”“What would you have done if I had been your baby?”
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Parental Involvement…
• Parent(s) always present helping
• Parent(s) provide comfort
• Parents learn to speak the truth and not reframe the past
• Timeline and life book are ongoing projects
A Tool-Box of TechniquesTelling the narrative “story”…
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The Life Book
A BOOK THAT RECORDS A CHILD’S HISTORY FROM THE BIRTH PARENTS TO THE
PRESENT
A Tool-Box of Techniques
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A Tool-Box of Techniques
The Timeline
•Allows child to place emotions in the right place
•Provides for concepts of past, present and future
•Helps child understand permanency – “forever”
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Music is the Language of the Spirit
A Tool-Box of Techniques
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• Researchers have hypothesized which came first: music or language
• Listening to music is an activity even when it’s background noise.
• Keeping time, postures change to reflect the story, evokes emotion.
• Brings up memories and feelings associated with that time.
A Tool-Box of Techniques
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Preverbal Trauma
Challenges…
• Trauma occurring before the development of language.
• Narrative memory has not developed fully.
• Sensory information still filters through the amygdala.
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There’s a lot going on in there!!
• Asymmetric differences between the left and
right hemispheres in adults.• This asymmetry is reversed in the fetus and may carry into early childhood. • Injury or trauma introduced at this time
can lead to an overdevelopment of the right side hemisphere.
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A Tool-Box of Techniques
Interventions
Airplanes
What happens if the airplane crashes? Everyone looks for the black box!
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Because the Black Box records EVERYTHING! The talking on the radio, the weather, turns, ups and downs…but it can’t tell the difference among people or ‘now’ and ‘back then.’ It doesn’t really think…it just records information and feelings so we can keep ourselves safe.
A Tool-Box of Techniques
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Everyone has a Black Box in their brain.
• It’s how we learn. • It can’t tell the difference between good and bad,
right or wrong, or even moms. • It’s main job is to tell us if it is safe or dangerous. • Maybe there’s a part in your Black Box that
recorded moms are mean and hurt their kids?
• I think I can help you fix it if you want.
A Tool-Box of Techniques
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• Children’s Books• Journaling• Art• Role-plays• Photos• Videos
A Tool-Box of Techniques
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A Tool-Box of Techniques
NurtureRepeating the “Cycle of Needs”
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Eye contact• Staring contest• Play peek-a-boo
• Look at each other and name ways you
match• Candy kiss hunt
• Face painting• “I love you” in soap
on mirror
A Tool-Box of TechniquesNurture
Touch• Styling hair
• Scratching back• Hand on the
shoulder• Hold hands while
walking• Kisses
• Clapping games• Hugs, hugs and
more hugs!
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A Tool-Box of TechniquesNurture
Talking•Sing together
•Read together
•Talk in the car
•Nursery rhymes
•Trace a word on your child’s
back•Identify faces
What a beautiful baby!
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A Tool-Box of TechniquesNurture
Smell•Lotion•Candle
•Bake cookies
Warmth•Dry mittens in
the dryer•Hot chocolate
•Pup tent•Special blanket
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A Tool-Box of TechniquesNurture
Motion•Blow bubbles
•Fly a kite•Rock
•Catch fireflies•Make a snow angel
•Shoot baskets
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A Tool-Box of TechniquesNurture
Food•Have a banana split for
dinner•Go on a picnic
•Say, “Yes, you may have a cookie after
dinner•Have a tea party
•Eat by candlelight with the kids
•Cut sandwiches into heart shapes
•Sprinkle chocolate chips on pancakes
Nurture with rather than battle over food
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Structure• The therapist and parents select and lead
the activities. This helps the child develop self-control.
Engagement• Offers stimulation, variety and a fresh view
of life-the child understands that surprises can be fun!
Nurture• Soothing, quieting, caretaking activities
make the world feel safe, predictable and secure
Challenge• Helps the child take a mild age-appropriate
risk. This promotes feelings of competence and confidence. Stresses cooperation
A Tool-Box of Techniques - Theraplay
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Improved flexibility, strength, balance, muscle tone
Increases the individual’s awareness of their breathing, and then teaches way to regulate breathing. This is important for calming down.
Pizer, Ann. Benefits of Yoga. [online].http://yoga.about.com/od/beginningyoga/a/
benefits.htm
A Tool-Box of TechniquesYOGA
Taming the Monkey Mind • This is the mind that jumps
from thought to thought like a monkey jumps from tree to tree.
• Emphasis is on being in the present moment. The mind gains the ability to focus and concentrate.
Stress relief via stretching. • Stress-related tension is
stored in the body, making a person feel tight, and often causing pain.
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• Helps in relieving discomfort from gas, colic, and constipation
• Improves blood circulation • aids in digestion • Improves quality and
amount of sleep• Enhances development of
the nervous system and Stimulates neurological development (brain function and brain development)
• Reduces aggression (Cozolino)
• Increases alertness and heightened awareness
• Reduces stress hormones • Improves immune function • Stimulates oxytocin, the
“nurturing hormone” • Deepens bonding: • Stimulates growth and
healthy development of body, mind and spirit
• Relaxing and soothing
International Association of Infant Massage. What are the Benefits of Infant Massage? http://www.iaim.ws/faqs.html
A Tool-Box of TechniquesInfant Massage
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“Training for the Brain”
A Tool-Box of TechniquesNeurofeedback
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Research
Vineland Adaptive Behavioral Scales
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Communication Domain Receptive Expressive Written
Daily Living Skills Domain Personal Domestic Community
Research
Socialization Domain Interpersonal Relationships Play and Leisure Time Coping Skills
Motor Skills Domain Gross Fine
Behavior Internalizing Externalizing
The Vineland Measures Development…
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Chronological Age 4 years, 4 months 5 years, 7 monthsCommunication• Receptive 1 year, 3 months 1 year, 6 months• Expressive 2 years, 6 months 3 years, 5 months• Written 4 years, 5 months 4 years, 11 monthsDaily Living Skills• Personal 3 years, 1 month 5 years, 0 months• Domestic 4 years, 6 months 5 years, 6 months• Community 3 years, 1 month 4 years, 5 monthsSocialization• Interpersonal Relationships 1 year, 1 month 2 years, 0 months• Play and Leisure Time 0 years, 4 months 0 years, 8 months• Coping Skills 1 year, 10 months 3 years, 4 monthsMotor Skills Domain• Gross 2 years, 1 month 4 years, 11 months• Fine 3 years, 6 months 4 years, 7 monthsBehavior• Internalizing Clinically Significant Clinically Significant• Externalizing Elevated Elevated
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Chronological Age 6 y, 0m 7 y, 0 m 8y, 3mCommunication• Receptive 1 y, 6 m 1 y, 11 m 2y, 2m• Expressive 3 y, 2 m 5 y, 0 m 4y, 6 m• Written 5 y, 2 m 6 y, 9 m 7y, 9 m Daily Living Skills• Personal 4 y, 7 m 6 y, 1 m 6y, 6m• Domestic 4 y, 4 m 3 y, 11 m 7y, 7m• Community 3 y, 7 m 5 y, 5 m 5y, 5mSocialization• Interpersonal Relationships 0 y, 3 m 2 y, 3 m 2y, 5 m • Play and Leisure Time 0 y, 9 m 2 y, 10 m 2y, 10m• Coping Skills 1 y, 6 m 2 y, 3 m 2y, 2mMotor Skills Domain• Gross 4 y, 5 m 5 y, 11 m 6y, 10m• Fine 6 y, 6 m 6 y, 6 m 6y, 10mBehavior• Internalizing CS CS CS• Externalizing CS CS CS
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Chronological Age 7 years, 11 months 9 years, 1 monthsCommunication• Receptive 1 year, 11 months 2 years, 11 months• Expressive 6 years, 4 months 6 years, 7 months• Written 9 years, 0 months 10 years, 8 monthsDaily Living Skills• Personal 6 years, 1 month 6 years, 6 months• Domestic 5 years, 5 months 9 years, 6 months• Community 7 years, 6 months 8 years, 7 monthsSocialization• Interpersonal Relationships 1 year, 1 month 1 years, 9 months• Play and Leisure Time 2 years, 9 months 5 years, 3 months• Coping Skills 1 year, 6 months 3 years, 5 monthsMotor Skills Domain• Gross Age Equivalent Age Equivalent• Fine 4 years,11 months 6 years, 10 monthsBehavior• Internalizing Clinically Significant Elevated• Externalizing Clinically Significant Elevated
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Chronological Age 11 years, 1 months 12 years, 5 monthsCommunication• Receptive 1 year, 9 months 3 years, 11 months• Expressive 5 years, 11 months 7 years, 7 months• Written 9 years, 2 months 10 years, 10 monthsDaily Living Skills• Personal 5 years, 11 month 11 years, 3 months• Domestic 7 years, 7 months 9 years, 6 months• Community 8 years, 11 months 9 years, 6 monthsSocialization• Interpersonal Relationships 0 year, 11 month 3 years, 7 months• Play and Leisure Time 3 years, 2 months 9 years, 3 months• Coping Skills 2 year, 3 months 5 years, 6 monthsMotor Skills Domain• Gross Age Equivalent Age Equivalent• Fine Age Equivalent Age EquivalentBehavior• Internalizing Clinically Significant Elevated• Externalizing Clinically Significant Elevated
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Part III
Parents Need Nurture Too!
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Parents Need Nurture Too!
Complex Trauma creates a ComplexFamily System
Most adoptive families are healthy prior to the arrival of a child with a history of complex trauma.
However, the family often appears unhealthy upon entering services.
The state of the family is a response to the challenges involved in parenting a child with complex trauma issues.
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Trauma, by definition…
A single experience or an enduring or repeating event or events, which completely overwhelm the individual’s ability to cope—consumption and depletion of coping skills.
There is frequently a violation of the person’s familiar ideas—expectations—about the world, and the person is put in a state of confusion and insecurity—cognitive dissonance.
This is also seen when people or institutions depended on violate or betray the person in some unforeseen way—isolation.
It usually involves a feeling of complete helplessness in the face of a real or subjective threat to one’s life or to that of a loved one’s life, integrity and sanity—losses.
There is also an inability to integrate the emotions—grief and negative emotional climate—involved with the traumatic experience.
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The Dynamics of the Complex Family System
ExpectationsCognitive DissonanceThe Consumption and Depletion of
Coping SkillsThe Emotional Roller-CoasterIsolationA Sea of Grief
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I want to help a child in need I am unable to have children I heard an ad on the radio Love will be enough I know what they have been through My spouse or partner wants to adopt I thought a child would strengthen our marriage A relative’s child needs my help I want my children to have more siblings I want to adopt a young child I don’t want to deal with birth parents I didn’t expect to adopt (foster parents)
The Dynamics of the Complex Family SystemExpectations
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I expect …• my partner to support me• parenting to resolve past issues• my faith to remain strong• my extended family and friends to be
supportive• to be supported by professionals• to be supported by society at large
The Dynamics of the Complex Family SystemExpectations – Additional Layers
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Typically-Developing Children
“I expect to have a playmate”
The Dynamics of the Complex Family SystemExpectations
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The Adoptee
“I think you will abuse me.”
“I think I am moving somewhere else.”
“I think you are another orphanage.”
“I am unlovable.”
The Dynamics of the Complex Family SystemExpectations
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The Dynamics of the Complex Family SystemExpectations
Expectations and reality collide
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Cognitive Dissonance
is defined as inconsistencies between expectations and experiences. As humans, we do not like inconsistency.
the greater the inconsistency, the more motivation there is to reduce it.
(Festinger, 1957)
The Dynamics of the Complex Family SystemCognitive Dissonance
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Perhaps the greatest source of cognitive dissonance is the invisible quality of mental health issues.
“Why can’t anyone see his problems?”
“Why are they always blaming us?”
The Dynamics of the Complex Family SystemCognitive Dissonance
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Adjusting Expectations – Achieving Cognitive Consonance
In evaluating expectations and experiences, our goal is to draw conclusions. We must decide:
• which expectations need to change because they have no rational basis
• which expectations have created losses that need to be grieved
• which expectations need to change because they cannot be fulfilled
• which expectations are valid and can be fulfilled
The Dynamics of the Complex Family System
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“Nothing works!”“We’ve tried it all!”
The Dynamics of the Complex Family System
The Consumption and Depletion of Coping Skills
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Ineffective Coping Styles - Parental
PunitiveAccommodating – “I give in”Making Extraordinary EffortsEmotionally Withdrawn “Yes, but…”Split
The Dynamics of the Complex Family System
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Ineffective Coping Styles – Healthy Kids
WithdrawnSelf-SacrificingActing OutRegressed “I’ll Cover for You”Victim
The Dynamics of the Complex Family System
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Ineffective Coping Styles – Repeating the PatternsTrauma Reenactment or Compulsive Repetition
Children who have experienced trauma alter the dynamics of the adoptive family in a manner that causes a repetition of their abandonment, abuse, neglect, deprivation or life with a drug addict. Their trauma is reenacted, albeit on a smaller scale, within the adoptive home.
(van der Kolk, 1989)
The Dynamics of the Complex Family System
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The child who is compulsively repeating his traumatic experience needs the presence of strong attachment figures—adoptive parents
The Dynamics of the Complex Family System
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and Effective Coping Styles
Alter coping and attachment styles&
Provide New Parenting Tools
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Parenting Pearls…Control, Control, Control
What you want to controlWhat you need to controlWhat you can controlWhat you should not controlWhat you cannot control
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72
Pick and choose carefully
Avoid control battles
Win the ones you take on
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Parenting Pearls…Developmental Parenting
“Developmental interruptions result in delays that leave the individual developmentally immature”
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Developmental Delays
Cause and Effect Thinking
Problem-Solving Skills
Moral Development
Social Skills
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75
Ineffective Parenting Tools
Rewards
Incentives
Removal of Privileges
Time Out
Grounding
IsolationKeck and Kupecky PARENTING THE HURT CHILD
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and Effective Coping Skills
• Natural and Logical Consequences• Paradox
• Joining In• Choices• Time In
• Praise – “Global” vs. “Specific”• Prescribing Symptom
• “Consistent” vs. “Unpredictable”
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No:ThreatsRemindersWarningsBribes
Ineffective Parenting Tools
Less Talk
More Action!
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Parenting Pearls…
Too much talk causes too little listening
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The Emotional Roller-CoasterThe Impact of Stress on the Adoptive Family
Child arrives with unresolved emotions
Child acts out behaviorally
Parents’ own unresolved issues are triggered.
Child and parent engage in negative emotional interactions.
A Negative Emotional Climate is Created
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Triggers are identifiable situations or events that can create emotional upheaval.
The Emotional Roller-CoasterTriggers
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• Mother’s/Father’s Day • Birthdays • Holidays • The anniversary of the
adoption • Anniversary of removal
from birth family• Illness or death of
adoptive parent • Divorce • School-related projects
and classes
The Emotional Roller-CoasterTriggers
• Airplane rides • Visits with birth
siblings • Birth or adoption of a
child• Kindergarten or first
grade • Beginning and end of
each school year• Puberty• Questions/comments
from strangers
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Facing Frustrations
Avoid Approaching Storms
Reduce Angry Reactions
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Parenting, healing forming strong attachments, etc. are about reactions, not consequences.
The Emotional Roller-Coaster“Reactions” not “Consequences”
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Isolation
• Support system shrinks• Marital tension• Time demands• Chaos• Behaviors (socially unacceptable)• Financial strain• Diminished family fun• Lack of services
Clip art
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A Sea of Grief
Grief—the emotional response to loss—is perhaps the most significant dynamic to develop within the adoptive family parenting a child with mental health issues.
When it comes to the experience of loss, the primary distinction between death and mental illness is that mental illness is not broadly and publicly recognized as a significant loss, when in fact, loss may be the primary trauma for family members during the course of mental illness (Johnson, 1994).
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A Sea of Grief
Although losses abound, there is one central loss. That is, the loss of the person that their adopted son, daughter, brother or sister could have been.
Additionally, in families with persons with serious mental health illness, there is no difference between parents and siblings in their level of grief (Miller, Dworkin, Ward, and Barone, 1990).
Grieving is a chronic—persistent and lasting—process.
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Positives - Adoptees
More likely to complete high school or the equivalent
More likely to attend and complete college Less likely to become teen parents Less likely to abuse drugs and alcohol Less likely to have mental health problems Less likely to be arrested and incarcerated More likely to be employed More likely to have adequate incomes More likely to have health insurance
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ParentsTypically-
Developing Children
Positives
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Books by the
Attachment and Bonding
Center of Ohio
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Gregory C. Keck, Ph.D.Attachment and Bonding Center of Ohio
12608 State RoadSuite 1
Cleveland, OH 44133440-230-1960
www.abcofohio.net