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ASSESSING CHILDREN WITH COMPLEX TRAUMA AND DISORDERS OF ATTACHMENT

ASSESSING CHILDREN WITH COMPLEX TRAUMA AND DISORDERS OF ATTACHMENT. Arthur Becker-Weidman, Ph.D. Director Center For Family Development. What we will be covering. What is Complex Trauma? Treatment focused assessment Parent assessment Child Assessment. Common Issues.

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ASSESSING CHILDREN WITH COMPLEX TRAUMA AND DISORDERS OF ATTACHMENT

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  1. ASSESSING CHILDREN WITH COMPLEX TRAUMA AND DISORDERS OF ATTACHMENT Arthur Becker-Weidman, Ph.D. Director Center For Family Development (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  2. What we will be covering • What is Complex Trauma? • Treatment focused assessment • Parent assessment • Child Assessment (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  3. Common Issues • Attachment Difficulties. • National Adoption Center: 52% of adoptable children have attachment disorder symptoms. • Other Mental Health Issues. • Mood Disorders. • 50 – 60% of children in US foster care who have RAD also have Bipolar I Disorder. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  4. Common Issues • Prenatal Exposure to Chemicals • ARND • No safe level • Other drugs • Sensory Integration Disorders • Neurological involvement • Learning problems (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  5. What is Complex Trauma? • Complex Trauma refers to the effects of: • CHRONIC • EARLY • MALTREATMENT • IN A CARE-GIVNG RELATIONSHIP (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  6. Domains of Impairment • Attachment • Biology • Emotional Regulation • Dissociation & Defenses • Behavioral Regulation • Cognition • Self-Concept (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  7. Complex Trauma : Most Frequent Difficulties Affect Dysregulation Attention/Concentration Negative Selff Image Impulse Control Aggression Risk-taking (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  8. Complex/developmental Trauma (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  9. Domains of Impairment: ATTACHMENT • Problems with relational boundaries • Lack of trust • Social isolation • Difficulty attuning with other’s emotional states • Lack of empathy • Lack of secure base (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  10. Domains of Impairment: BIOLOGY • Sensory-motor developmental dysfunction. • Analgesia • Sensory-integration dysfunction • Somatization • Increased medical problems (CDC’s ACE’s studies). (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  11. Domains of Impairment: EMOTIONAL REGULATION • Poor affect regulation • Difficulty identifying and expressing emotions. • Difficulty identifying and describing internal states: Undeveloped Reflective Function (Peter Fonegy) • Difficulty communicating needs and wishes. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  12. Domains of Impairment: DISSOCIATION • Distinct alterations in states of consciousness • Amnesia • Depersonalization and derealization • Discrete states of consciousness with discrete memories, affect, and functioning. • Impaired memory for state-based events • Really a defense against overwhelming stress. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  13. Domains of Impairment: BEHAVIORAL REGULATION • Difficulty regulating impulses. Poor impulse control. • Self-destructive behavior • Excessive risk-taking behavior • Aggression • Pathological self-soothing behaviors • Sleep problems (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  14. Domains of Impairment: BEHAVIORAL REGULATION • Disturbances of eating • Substance abuse • Excessive compliance • Excessive defiant behavior • Problems complying with rules. • Reenactment of trauma in behavior or play. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  15. Domains of Impairment: COGNITION • Difficulty with regulating attention • Difficulty with Executive Functions: planning, judgment, initiation, use of materials, self-monitoring, etc. • Difficulty processing new information • Difficulty focusing and completing tasks (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  16. Domains of Impairment: COGNITION • Difficulty planning and anticipating: problems with cause-effect thinking. • Learning lags • Difficulty with language development: gap between receptive and expressive communication abilities. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  17. Domains of Impairment: SELF-CONCEPT • Fragmented and disconnected autobiographical narrative • Poorly developed sense of separateness • Disturbed body image • Low self-esteem: internal working model of self as unloved/unlovable, not valued/valuable, as “garbage.” • Excessive shame. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  18. Other effects of chronic maltreatment • Delay of social and emotional development. • Often receptive communication lags expressive; looks like ODD. • Interpersonal relationships often delayed • May have higher functioning in daily living skills. • Overall adaptive level often several years behind chronological age. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  19. Convergence of Types of Violence • Children exposed to domestic violence • 15 times more likely to be abused than average • 30-70% overlap with child abuse • Serious risk of sexual abuse • Battered women • Twice more likely to abuse their children than comparison groups (Osofsky, 2003; Edleson, 1999; Margolin & Gordis, 2000; McCloskey, 1995) (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  20. Children Exposed to Domestic Violence • Double the rate of psychiatric problems than comparison groups • Psychiatric problems persist • Increased risk of adult family violence • Younger children more vulnerable (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  21. Other effects of chronic maltreatment • Delay of social and emotional development. • Often receptive communication lags expressive; looks like ODD. • Interpersonal relationships often delayed • May have higher functioning in daily living skills. • Overall adaptive level often several years behind chronological age. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  22. (c) 2008 Center For Family Development www.Center4FamilyDevelop.com 716-810-0790

  23. (c) 2008 Center For Family Development www.Center4FamilyDevelop.com 716-810-0790

  24. Evaluation • Screen for a variety of mental health and other common issues associated with histories of maltreatment. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  25. Outline for a Thorough Evaluation • Review of all records • Session One: Session with Parents regarding child • Evaluation of Parents • Use of various tests and questionnaires • Session Two: Assessment of Child • Session Three: Session to review assessment and treatment recommendations. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  26. Outline for a Thorough Evaluation • Assess for various mental health conditions: Bipolar Disorder, ADHD, etc. • Screen for neuro-psychological issues caused by early maltreatment • Sensory-Integration • ARND (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  27. Previous Records • Protective Service Reports • Police Reports • Previous treatment records & evaluations • School records • Social histories, etc. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  28. PARENT ASSESSMENT (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  29. Why do some foster placements succeed? • Commitment of foster parent(s) (Dozier and Lindhiem, 2006) • Adequate information, knowledge, training, felt support. • Natal children are not adversely affected (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  30. Key dimensions for successfully parenting challenging children. • Parent(s) state of mind with respect to attachment • At 2-yr follow-up, 86% of children placed with parents, neither of whose AAI was secure at the time of placement, had the highest scores for attachment disorganization. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  31. Foster Children, Age 1-3 Years After 8 Months in Placement (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  32. Parent Session • Clinical meeting with caregivers • Child’s current functioning • Diagnostic interview to screen for various mental health difficulties and trauma-attachment difficulties • Parent’s state of mind with respect to attachment. (Use of AAI) • Insightfulness Assessment • Parent Commitment Assessment (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  33. Parent Session • Assess Process of interview • Why there? Their story • Chronology • Current symptoms and what is most challenging • What has been tried • Assessing parenting capacity: • Intersubjectivity • Commitment • Insightfulness (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  34. Key dimensions in parent work • Parent sensitivity • Parent state of mind with respect to attachment • Adult Attachment Interview • Parent attunement and intersubjectivity • Parent reflective capacity • Insightfulness Assessment • Parent commitment • Commitment Assessment (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  35. Parental Commitment • Commitment Ratings: • High: The parent provides evidence of a strong emotional investment in the child and in parenting the child. Descriptions of the child and the parent-child relationship clearly reflect a strong connection with the child. The child is fully integrated into the family. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  36. Parental Commitment • Commitment Ratings: • Low: The parent provides virtually no evidence of a strong and active emotional investment in the child or in parenting the child. The parent may be indifferent to whether the child remains in the parent’s care or may actually state that the parent hopes/desires the child will be removed. There is little evidence that the parent would miss the child. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  37. CLINICAL SESSION WITH CHILD (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  38. Clinical Interview with Child • Diagnostic Interview • Mental Status • Process of interview to assess state of mind with respect to attachment. • House-Tree-Person • Heart Drawing • 4 key questions • Assessing for indications of other conditions • Attachment Story Completion Test (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  39. Clinical Interview with Child • Four Questions • What is the thing you’ve done that you are most proud of? • What is the worst thing you’ve done? • What is the best thing that has ever happened to you? • What is the worst thing that has ever happened to you? (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  40. Clinical Interview with Child • Attachment Story Completion • SPILLED JUICE. While the family is seated at the dinner table, the younger child accidentally spills juice on the floor, and the mother exclaims about it. • HURT KNEE. While the family is taking a walk in the park, the younger child climbs a rock, falls off, hurts a knee, and cries. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  41. Clinical Interview with Child • Attachment Story Completion 3. STRANGE SOUND AT NIGHT. After the child is sent upstairs to go to bed, the child cries out after hearing a strange sound. 4. DEPARTURE. The parents leave for a weekend trip, with grandmother remaining behind to look after the two children. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  42. Clinical Interview with Child • Attachment Story Completion 5. REUNION. Grandmother looks out of the window on Monday morning and tells the children the parents are coming back. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  43. Clinical Interview with Child • House-Tree Person test • Heart Drawing (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  44. Specific tests • Child Behavior Checklist (CBCL; Achenbach, 1991) ** • Trauma Symptom Checklist for Young Children ** • Symptom checklist screener ** • Sensory-integration screener ** • Behavior Rating Inventory of Executive Function (Parent & Teacher) ** • Vineland Adaptive Rating Scales – II ** (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  45. Final Meeting with Caregivers • Review Assessment and Diagnoses • Mental Health Conditions • Attachment • Other issues requiring further evaluation • Sensory-Integration Disorders • Neuro-psychological assessment • Educational testing for LD (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  46. Final Meeting with Caregivers • Other issues requiring further evaluation • Developmental Screening • Developmental Pediatrician • Developmental neurologist • Treatment Recommendations • Parenting • Treatment (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  47. References Achenbach, T.M. (1991). Manual for the Child Behavior Checklist/4-18 and 1991 Profile. Burlington: University of Vermont, Department of Psychiatry. Becker-Weidman, A., (2006). “Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy,” Child and Adolescent Social Work Journal. Vol. 23 #2, pp. 147-171. Becker-Weidman, A., (2006). “Dyadic Developmental Psychotherapy: A multi-year Follow-up”, in, New Developments In Child Abuse Research, Stanley M. Sturt, Ph.D. (Ed.) Nova Science Publishers, NY, 2006, pp. 43 – 60. Becker-Weidman, A., (2007) “Treatment For Children with Reactive Attachment Disorder: Dyadic Developmental Psychotherapy,” http://www.center4familydevelop.com/research.pdf Becker-Weidman, A., (2009) “Effects of Early Maltreatment on Development: A Descriptive study using the Vineland,” Child Welfare, 88 (2). (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  48. References Becker-Weidman, A., (2011), Dyadic Developmental Psychotherapy: Essential Practices & Methods, Lanham MD: Jason Aronson. Becker-Weidman, A., (In Press), The Dyadic Developmental Psychotherapy Casebook, Lanham, MD: Jason Aronson. Becker-Weidman, A., & Hughes, D., (2008) “Dyadic Developmental Psychotherapy: An evidence-based treatment for children with complex trauma and disorders of attachment,” Child & Family Social Work, 13, pp.329-337. Becker-Weidman, A., & Shell, D., (Eds.) (2005). Creating Capacity For Attachment, Oklahoma City, OK: Wood ‘N’ Barnes. Second Printing, (2008) Center For Family Development. Becker-Weidman, A., & Shell, D., (Eds.) (2010), Attachment Parenting: Developing Connections and Healing Children, Lanham MD: Jason Aronson. Briere, J. (2005). Trauma Symptom Checklist for Young Children (TSCYC). Odessa, Florida: Psychological Assessment Resources. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  49. References Brown, J.D. & Bednar, L. M., (2006) Foster parent perceptions of placement breakdown. Child and Youth Services Review 28,1497-1511. Cook, A., Spinazzola, J., Ford, J., Lanktree, C., et. al. (2005) Complex trauma in children and adolescents. Psychiatric Annals, 35:5, 390-398. DHHS, (2005) Department of Health and Human Services (DHHS) (US), Administration on Children, Youth, and Families (ACF). Child maltreatment 2003 [online]. Washington (DC): Government Printing Office; 2005. [cited 2005 April 5]. Available from: URL: www.acf.hhs.gov/programs/cb/pubs/cm03/index.htm Dozier, M., Grasso, D., Lindhiem, O., & Lewis, E., (2007) “The role of caregiver commitment in foster care,” in D. Oppenheim & D. Goldsmith, (Eds.) Attachment Theory in Clinical Work with Children. NY: Guilford. Dozier, M. & Lindhiem, O. (2006) This is My Child: Differences Among Foster Parents in Commitment to Their Young Children. Child Maltreatment 11 (4), 338-345. Dozier, M., Stovall, K.C., & Albus, K. (1999) Attachment and Psychopathology in Adulthood. In J. Cassidy & P. Shaver (Eds.). Handbook of Attachment (pp. 497-519). NY: Guilford Press. (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790

  50. References (c) 2011 Center For Family Development. www.Center4FamilyDevelop.com 716-810-0790 Finzi, R., Cohen, O., Sapir, Y., & Weizman, A. (2000). Attachment Styles in Maltreated Children: A Comparative Study. Child Development and Human Development, 31, 113-128. Fisher, B.A., Burraston, P. & Pears, K. (2005) The Early Intervention Foster Care Program: Permanent Placement Outcomes from a Randomized Trial. Child Maltreatment 10 (1), 61-71. Friedrich, W.N. (2002). Psychological assessment of sexually abused children and their families. Thousand Oaks, CA: Sage. Gauthier, L., Stollak, G., Messe, L., & Arnoff, J. (1996). Recall of childhood neglect and physical abuse as differential predictors of current psychological functioning. Child Abuse and Neglect 20, 549-559. Greenberg, M. (1999). Attachment and Psychopathology in Childhood. In J. Cassidy & P. Shaver (Eds.). Handbook of Attachment (pp.469-496). NY: Guilford Press. Hesse, E., (2008). “The Adult Attachment Interview,” In J. Cassidy & P. Shaver, Handbook of Attachment, NY: Guilford.

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