Dyadic Mapping for Reflective Practice: Self, Parent, and Child - PowerPoint PPT Presentation

Neuro-Relational Framework (NRF) Dyadic Mapping for Reflective Practice: Self, Parent, and Child Name: Cathy Pope, MA,RN, MFTI Email Contact: pope-c@kcusd.com Date:10-9-15

Translating “what matters” in early brain development to an assessment & intervention process for infants and parents 3 steps to NRF: What Matters: • Step 1: Assess & intervene to • Stress Resilience versus improve stress and stress recovery Toxic Stress patterns in child and parent • “Serve & return” levels of • Step 2: Assess & intervene to high quality engagement improve the level(s) in the quality of engagement in relationships • Healthy development of • Step 3: Assess & intervene to brain networks and improve individual sources of circuits vulnerability (triggers) & resilience (toolkits) in brain networks

Brief Family History • Age of client(s) 24 months Khloe • Family constellation Josh -58 years old ( older children out of the home, 1 incarcerated) Barb- 25 years old Josh’s stepfather ( bed ridden) stays in back room and Josh provides IHHS Mason 4 yr. (1/2 sibling to Khloe lives with maternal GM) and occasionally visits Josh is unemployed, completed 7 th grade and describes himself as having a learning disability-limited reading and writing. He has been on Methadone treatment for 15 years. He works from the house and does mechanic repairs. He helps the neighbors out as needed. Cares for another older neighbor by running chores or doing minor house repairs. Barb completed high school. Stated she taught preschool at one time. She received Methadone treatment throughout her pregnancy and continues on Methadone currently. She stated she has social anxiety and panic disorder. She had an eating disorder when she was younger. Car accident at 16 years of age left her with chronic pain from a pelvic fracture.

Macro Level Overview Early Care & Education THINKING • Early Head Start In utero • Individual exposure to Methadone Routine pediatric care- counseling through BODY FEELING Parents & Children’s Health Center Behavioral health Child Recurrent hospitalizations Mental Basic Needs/ Methadone Clinic the first 14 months for Child Welfare • MFTI dyadic Health Medical immunocompromise treatment KC KIDS • Hypotonic-seeks Asthma/Pneumonia proprioceptive input • Received the Willbarger protocol for treatment • CVRC client for DD • EI Services thru KC Kids SENSING Developmental Disabilities Lillas & Turnbull, 2009

Case History Timeline • 2013 • Born at 34 weeks 8 day • Initial IFSP 2/20/15 hospital stay due to withdrawal syndrome. Placed on Methadone for 8 months. Lived with mom • Current July 2015 and dad. diagnosed with shingles September • 2013-14 Hospitalized 4 2, 2015 virus and times for 3 days typically for asthma asthma. Referred for Developmental Delay 12-18- 14 by PCP.

Step #1A: Stress and Stress Recovery Patterns

Sleep & Stress Patterns Sleep Cycles: Khloe sleeps from 10 pm to 8-9 am awakens at night reaching for pacifier with assistance naps from 3-5 pm Total sleep 13 hours Barb sleeps 8 hours without interruption Josh awakens 6 times/noc. for voiding Naps for 2-3 hours and sleeps 2-3 nap. Stress Patterns: Khloe 80% red, 10% combo, 5% blue, 5% green Barb 80%combo, 10% green, 10% red Josh 80% red, 10% green, 10% blue

Reading Non-Verbal Cues: Combo Zone A Baby’s Vigilant State:

Reading Non-Verbal Cues: Red Zone A Baby’s Flooded State:

Reading Non-Verbal Cues: Blue Zone A Baby’s Shut -Down State

Physiology Under Coordination Under Stress Child Parent Child Parent Rarely green Green X Rarely green X Zone Barb appears vigilant, eyes are X Khloe covers her eyes with her wide open, her tone elevates hand and cowers and her rate of speech Eyes are wide open increases. If flooded she leaves Combo Appears vigilant the room. Facial expression of pain Quavering voice Zone Tense, rigid posture Khloe scans the room quickly, Barb rolls her eyes, frowns or has a facial expression of has a facial grimace, speaks distress or anger, yells or sarcastically, and rate of speech screams, throws herself down increases. She often interrupts X on the floor, kicks or throws the speaker. things Yelling or screaming Constant motion Intense eye gaze Red Poor balance falls, trips a lot, Eyes roll upward Zone bumps into things, throwing Clenched jaw Direct intense eye contact Forced smile High pitched cry Loud yelling or screaming

Physiology Under Coordination Under Stress Child Parent Child Parent Rarely green Green X Rarely green X Zone Khloe has glazed eyes, prefers looking at objects Barb averts her gaze, no X rather than people. Her smiling, and limited Blue affect is flat. She does emotional expression. She just sits and doesn’t move not move much and limits Zone her exploration. often. She is in chronic back pain.

Parallel Process • Important information about how this family impacts my stress levels (step #1) • How does this child/parent impact my physiology? – Easily get to green and stay green? – Can steer me into red/blue/combo zones? – Any particular pattern?

Your Own Physiology Under Coordination Under Stress Child Parent Child Parent Stay green pretty well Green X with family x Zone When Barb becomes anxious, I My body posture tenses, my tend to detach and wait for her to shoulders become upraised, and “land”. I decrease my speech, and X X my gaze can be become intense my body movements lessen. Combo as I observe to determine the source of her anxiety. Zone I slow my speech, focus my gaze I slow my speech, lower my tone of on the parent’s responsivity, and voice, and lean forward or in. My move slowly toward the dyad. body posture tenses. X X Red Zone I soften my voice, turn or move toward Khloe, and sit in a relaxed “waiting” posture. I focus my gaze on Barb, speak slowly Blue and softly, and at times can become X X Zone tense in my body.

Step #1, “Before” Flooded DAD and child MOM & Hyperalert Child Alert Processing Hypoalert Mom Dad Child

Are there any toxic stress patterns? Recognize stress responses that are too frequent, too quick / intense, too long 4 Toxic Stress Patterns 1. Stress responses that occur too frequently and too quickly 2. Can’t adapt to “normal” challenges and transitions 3. Prolonged stress responses that take too long to recover (more than 10 to 20 mins) 4. Can’t recover from stress response back to baseline health (healthy sleep cycle, healthy awake state) McEwen

Family Stress Patterns Stress Patterns Over Time Date of Assessment Dec-14 Feb-15 Apr-15 May-15 Jul-15 Sep-15 Oct-15 0 1 Stress Pattern # 2 3 3 4 4 4 5 We hope to see an upward curve over time indicating that intervention is having a positive impact on family functioning.

Step #1B: Heart, Hand, & Head Patterns

Heart, Hand, and Head Patterns Under Coordination Under Stress Child Parent Child Parent Khloe engages in more Barb is unable to attend to Khloe feels anxious or Khloe’s needs as she becomes reciprocal gaze with her Barb is emotionally present, uncertain when her mother mother. She listens as overwhelmed by her resistance to following Khloe’s lead and becomes frustrated with non- her voice matches the receive guidance. She often Heart responding appropriately to compliance. gives up and says, “She doesn’t affective tone of the what she shows interest in. . listen to me, just her dad”. situation or experience. Listens and follows her Khloe cannot tolerate the Barb rarely uses directive parent’s guidance. abrupt, loud responses of her statements, rather asks whether Both parent’s are firm but father and becomes flooded or not Khloe would like to do direct. Fewer words are used and tries to escape the something. Josh becomes loud, Hand and more action oriented situation. insistent, and harsh. guidance and close proximity are used. Khloe is beginning to Barb will reflect on her own Khloe has limited reflective learn simple concepts about what might work, but is capacity at this point as she has like wait. unable to reflect about a approximately 30 words she Barb is quick to engage in automatic situation of concern with uses consistently to label, Head thoughts rather than adopt a slower Josh. request, greet, or protest. reflective stance.

Parallel Process • Important information about how this family impacts my stress levels (step #1) • How does this child/parent impact my relational style? – Brings out my Heart/Hand/Head at my best – Can stimulate my Heart/Hand/Head at my worst