Childhood & characterized by a tendency to maintain closeness - PDF document

12/4/2015 Treatment of Attachment: Disorders of An enduring emotional bond Childhood & characterized by a tendency to maintain closeness and warmth with Adolescence a particular person, particularly when under distress. Attachment Theory Basic human need Hardwired to attach to a primary caregiver 1 st 3 years plus fetal stage of development are critical Sensitive period that becomes less plastic w/ age Multigenerational Transmission Process ◦ 75-80% prediction rate! 1

12/4/2015 Attachment Theory Cont… Reciprocally reinforced cycle: ◦ Baby acts in reinforcing way to caregiver ◦This continues the caregiver’s behaviors that meet the child’s emotional and physical needs for safety and stability ◦Therefore reinforces baby’s continued behaviors and so on…. Attachment Theory cont… Baby Caregiver has a need gratifies Success or failure in meeting the needs determines the internal working model for views of self, others need and the world We use these models to self-regulate, face the world, choose actions and form attitudes. Attachment Cy Cycle Actions are chosen to influence surroundings in a way that generates responses that reinforce their Trust working models (self-fulfilling prophecies) experience Breakdown in reciprocity at any point can cause problems 2

12/4/2015 What do we get from secure What do we get from secure attachment? attachment? Learn basic trust and reciprocity with others Explore and learn w/ feelings of safety and security Develop the ability to self-regulate ◦ Emotional regulation ◦ Impulse control Foundation for core self and self-identity ◦ Competency ◦ Self worth ◦ Dependence vs. Autonomy Prosocial moral framework Defense against stress and trauma ◦ Resiliency ◦ Resourcefulness Common Diagnoses Associated w/ Areas of Functional Impairments & Disrupted/Disordered Attachment Symptoms cont… PTSD Axis II Disorders (including Cognition: Interpersonal: ◦ Negative Cognitive Triad ◦ Lack Trust Borderline Personality ODD Disorder and Antisocial ◦ Lack cause & effect thinking ◦ Intense Need for Control ◦ Attention Problems ◦ Manipulative Personality Disorder) Failure to thrive ◦ Learning Problems ◦ Primary Process Lying Depression Conduct Disorder ◦ Unstable Relationships ◦ Indiscriminate Affection Bipolar Disorder Anxiety ◦ Blaming Others Child/Adolescent Antisocial Drug/Alcohol Abuse and ◦ Victimized Dependencies Behavior ◦ Victimizes Selective mutism Areas of Functional Impairments & Attachment Disorders Symptoms cont… Physical: Moral/Spiritual: Reactive Attachment Disorder ◦ Poor Hygiene ◦ Lack of Empathy ◦ Poor Reaction to Touch ◦ Lack of Faith RAD ◦ Elimination Issues ◦ Lack of Remorse ◦ Feeding Issues ◦ Lack of Meaning ◦ Accident Prone ◦ Lacking other Pro-Social Values ◦ High pain tolerance Disinhibited Social Engagement ◦ Genetic Predispositions ◦ Identification w/ Evil and Other Anti-Social Values DSED 3

12/4/2015 Treatment Of Attachment Disorders Treatment Effective interventions includes Multimodal Treatment providing a secure and nurturing ◦ Family Therapy is Key environment, exposure positive ◦ Individual Therapy parenting practices, and opportunities ◦ Medication Management to develop interpersonal trust and ◦ Case Management Services social relationships. Curative Factors Curative Factors LOVE: ATTUNEMENT: ◦ Warm accepting & nurturing ◦In sync with child’s needs, emotions and working model ◦ Provide loving social cues (eye contact, smiles, laughter) ◦ Send messages that you can provide what the child needs based on accurate understanding of ◦ Cuddle time the world through their eyes ◦ Nourishment ◦ Genuine care, concern and commitment 4

12/4/2015 Curative Factors Curative factors EMPATHY: POSITIVE AFFECT: ◦ Experience and display positive ◦ Empathic to the child, not emotions with the child angry, hostile or distant ◦ Let them know you will not allow them to control your feelings Curative Factors Curative Factors SUPPORT CHILD: STRUCTURE: ◦ Reestablish authority (who is in control?) ◦ Provide support according to what they need and at their developmental level ◦ Consistency and follow through are important, however sometimes you can be inconsistent with results. ◦ As the focus moves from rules, expectations and ◦ Unwavering structure with expectable consequences consequences begin to support independent achievement ◦ Consequences without warnings and second chances ◦ Consequences are the child’s choice for deciding not to comply, not ◦ Praise behaviors briefly. Do not overpraise or make something “mean” caregiver is doing to them global positive statements about the child ◦ Highly structured routine ◦ Provide them time to learn self-control ◦ Accepting the child’s past and family as a part of them (Does not include acceptance of what they did to the ◦ No responsibility without demonstrating responsibility child) ◦ REMEMBER: Firm but not harsh ◦ Encourage talks about events and feelings pertinent to the child ◦ Listen What Works cont … Curative Factors SUPPORT PARENT: ◦ Safe environment ◦ Assist parents to remain open, accepting and attuned ◦ Constancy ◦ Support parents, validate and link to others when at all possible ◦ Boundaries ◦ Use respite when overwhelmed ◦ Limits ◦ Avoid unnecessary power struggles (You Will Lose) ◦ Be aware of your own weaknesses and triggers ◦ Collaborative work w/ parents ◦ Learn to recognize that the behavior is directed at the role (caregiver) not the person ◦ Supportive work w/ parents ◦ Use collaborative multi-systemic approach 5

12/4/2015 What Doesn’t Work: Traditional therapies Anger Childhood Blaming the parents Global Praise Seeing the child as victim Equality DEPRESSION Rewards & other behavioral incentives Withholding love Punishment Timeout Grounding Deprivation DEPRESSION Childhood Depression Child Sign of Depression Lack Defense Mechanisms ◦ Drop in Grades Lack Coping Skills ◦ Concentration Problems ◦ Psychomotor Agitation Dependent Upon Others for Security & ◦ Mood Swings Stability ◦ Aggressive Behavior Vulnerable Population ◦ Interpersonal Conflict ◦ High Boredom/Apathy Adolescent Depression Treatment for Depression Any given time 3-5% ◦ Cognitive Behavioral Therapy/Positive Psychology 20% have had a MDD episode by 18 ◦ Younger Children Play Therapy/Art Therapy Females 2-3xs more likely ◦ Medication Management: However, there are Often Co-Morbid significant concerns about selective serotonin reuptake inhibitors (SSRIs) increasing suicidality. ◦ Anxiety ◦ They have been found to be superior to cognitive Creates Additional Risk Factors behavioral therapies for severe depression. ◦ Substance Use ◦ Suicide/Self Harm ◦ Additional Depressive Episodes 6

12/4/2015 Adolescent Depression Disruptive Mood Regulation Disorder (DMDD): Any given time 3-5% DMDD is characterized by chronic irritability and severe mood dysregulation, including recurrent episodes of temper 20% have had a MDD episode by 18 triggered by common childhood stressors. Anger reactions Females 2-3xs more likely are significantly exaggerated in both intensity and duration. DMDD is considered a depressive disorder although Often Co-Morbid behavior symptoms, they are reflective of an irritable, angry ◦ Anxiety or sad mood state. Creates Additional Risk Factors Symptoms need to exist beyond age 6 and behaviors and ◦ Substance Use the diagnosis has to be made before the age of 18. ◦ Suicide/Self Harm ◦ Additional Depressive Episodes Treatment DMDD Multimodal Therapy: ◦ Family Therapy focused on parenting skills and working with parents on issues related to not personalizing their child’s behavior. ODD ◦ Individual Therapy focusing on emotional regulation and coping skills ◦ Medication Management ◦ Case management services ODD Who is the Oppositional Child? 7

12/4/2015 ODD and Treatment Treatment Focus ODD is a relational Disorder and therefore the most Improving the quality of the parent child appropriate Treatment is family therapy. Individual can be relationship combined to increase coping skills. Helping parents develop parenting strategies that Age 3 to 7: Parent Child Interactional Therapy (PCIT) do not reinforce the oppositional behavior 1, 2, 3 Magic 3 to early Teen May explore possible underlying reasons for Family Therapy focusing on parenting strategies that do not oppositional behavior reinforce oppositional behavior. What creates or reinforces What Makes a child oppositional behavior Oppositional First and Foremost the oppositional behavior pays off with some type of reward. Examine the focus of the Child Child’s demonstration of Vs. the Focus of the Parents power The parents focus is on the resolution of the dispute. Power can be demonstrated in many ways: ◦ The child’s ability to make the parent angry The child’s focus is not on the outcome of the argument but on winning the argument. Winning does not necessarily ◦ Cause an argument between mother and father mean that the outcome of the argument leads to desired ◦ Delay going to an appointment or completing a objects or activities. task For the oppositional child winning means that he or she is ◦ Increasing the tension in the house able to demonstrate his or her power. Power can be demonstrated in many ways. 8