Attachment, Self-Regulation, and Competency - …

1 Attachment, Self-Regulation, andCompetency A , , ,TheTraumaCenteratJusticeResourceInstitu te,Brookline, ,BostonUniversityMedicalSchool,Boston;cl ini-caldirector,TheTraumaCenter;andco-di rector, :KristineKinniburgh,TheTraumaCenter,227 Bab-cockSt.,Brookline,MA02446;or caregivingsystemthalisintendedtobethechi ld' , [vulnerabilitiesacrossmanydifferentdomai nsoffunctioning:cognitive,affective,beha vioral,physiological,relational, ,inthecourseofdevelopment,mostchildrenha vethechancetoinvesttheirenergiesindevelo pingvariouscompetencies, developmentalandsocialcontextandthatcana ddressa con-tinuumoftraumaexposures, :safety, ,traumaticexperienceintegration,relation alengagementorattachment,andpositiveaffe ctenhancement(CooketaI.)]

2 ,seepage390, ).1 Further,thereis a ,..424 PSYCHIATRICANNALS3S:SIMAY2005 EDUCATIONALOBJECTIVESPSYCHIATRICANNALS35 :. ,Selt'-Regulation,andCompetency(ARC)mode lprovidesa component-basedframeworkforin-tervention (Figure,seepage426),Theframeworkisground edintheoryandempiricalknowledgeaboutthee ffectsoftrauma, , , , , Self-Regulation, andCompetency:a ! Classroom-8saedInlervention(Ma<;y).Pa,en t-ChildPsychotherapy(Lieberman&VIInHom), R98~lifeHeroes(Kavon).SPARCS(de_etlll.). STAIR( ( )treatmentchoices,whilerecognizingthenee dforindividuallytailoredinterven-tionasw ellastheimportantroleofeachpractitioner' ;whilerecognizingtheimportanceofprocessi ngtraumatic memoryandexpe-rience, ,stabilizinginternaldistress,andstrength eningthesecurityofthecaregivingsystem, , " attachment "describestheinterac-tionsbet weenchildrenandtheircaregiv-ersthathavea longstandingimpactonthedevelopmentofiden tityandpersonalagency,earlyworkingmodels ofselfandother,andthecapacitytoregulatee mo-tions.

3 " ,impairedattachmenthasbeenlinked10multip lenegativeout-comes, ,inconsistency,orunpredictability;multip leseparationsduetoout-of-homeplacementor caregiverhospitalization, ; ,neglectful,orrejectingcare-givingis forcedtomanageoverwhelmingexperiencesbyr elyingonprimitiveandfrequentlyinadequate copingskillssucha~ , , :building(orrebuilding)healthyattachment sbetweenthosechildrenwhohaveexperiencedt raumaandtheirt.:aregivers; : Creatinga structuredandpredictableenvironmentbyest ablishingritualsandroutine:PSYCHIATRICAN NALS35:5 IMAY2005 IndividualRoutines&Rituals Workwithchildtobuilddailypatterns. Havepredictabletherapyroutines.

4 " "regulationskills. therapeuticrela-]. Identifylng,labeling, Familialroutinesformorn- Psychoeducationing,mealtimes,bedtime,etc . Normalization SupportcaregiversinI self -monitoringconsistentandappropriate' Support BuildmilieuconsistencyandI Promoteeducationabout Dyadicworkthatinvolvesmodelinguseoflangu age,touch,nonverbalgestures,etc.,totunei ntoandre-spondtochild' ;reframenegativelioppositionalbehaviors. ! Teachstaffaffectmanage-imentskills. Provideforumsforstaffsup-port;encourages elf-care ,trig-gers,andbehaviors., Trainin trauma-informedresponse. Teacha parentwhenandhowtousereinforcementthroug hmodeling,directteaching,andbehavioralst rategies.

5 Buildmilieureinforcementsystems. Expandfocusfrom problem-centered"tostrengths-based. Expandsystemicdefinitionsof"'succe5s~ Increasingcaregivercapacitytoman-ageinte nseaffect; Improvingcaregiver-childaltunementsothat thecaregiverisabletorespondtothechild'sa ffect,ratherlhanreacttothebehavioralmani festation:and Increasinguscofpraiseandreinforce-ment,t ofacilitatethechild' ,familial,andsystemiclevels( ,theseprinciplesaredesignedtotranslateto otheradultswhohaveongo-inginteractionswi ththechild, :SIMAY2005forthedevelopmentofallothercom pe-tencies,includingtheregulationofemo-t ion,behavior, (ie,shutdown)orlabile(ie,explosive). self -REGULATIONT heoreticalUnderpinningsTraumatizedchildr enfrequentlyaredisconnectedfromtheirowne motionalexperience-thatis, (ie,shame, self -blame,isolation)duetochil dren' ,emotionsexpressedbyothersmaybemisinterp retedaspotentialdan-gercues, (ie,shutdown)orlabile(ie,ex-plosive).)

6 Followingtheonselofintenseemotionalstate s,thesechildrenmayhavedifficultycalmingd ownandeitherremainina negativeaffectivestateforanextendedperio doftimeorrelyonmaladaptivecopingmethods, suchassubstanceuseandself-injury, "trauma"describesmanytypesofexperiences, commonacrosstraumaexposuresistheinitia-t ionofbiologicallydriven"fight-flight-427 !I .Cuechildinuseofskills., Observechangesinmodulation:"YouIseema littlebitcalmernow." ,support,praise, oneofyourchild' !. :I .BuildunderstandingofdegreesofIfeeling(e g,feelingthermometers,numberscales(0-'00 ),circleslices).I'Up-regulation(eg,groun ding,physicalImovement,mutualengagement) .: Down-regulation(eg,breathing,muscleirela xation,visualization/imagery).

7 (eg,"TurnIuptheVolume,"big/smallmovement s,iyoga/dance/martialarts). Buildforumsforregularcommunication:writt en,residentmeetings; Usereflectivelisteningskills. Modellabeling. Createspace(eg,bulletinboards,walls)tied tothemeofemotion; ~PIlSsion, Expandawarenessofaffectthroughfeel-I'Nor malizeemotionalexperience;, Connectaffecttobehaviorandexperi-! ;.Build"feelingstoolboxes"(eg,anger,joy, ,worry). Connectaffecttophysicalexperiencei Varymeansofexpression(eg,verbal,throughb odydrawingsandroleplay/Idrawing/painting /arts,creativewriting, ,drama/roleplay).!.Usephysicalstrategies (eg,exercise,,movement,feelingsbasketbal l). \. ,goaroundthe,dinnertable(ie,"best"and"wo rst"oftheday;biggestfeeling;etc.)

8 Askquestionsthatexpandcommu-nication:"Ho wdidyoufeelwhenthathappened?". Usereflectivelisteningskillstonameobserv edaffect,linkaffecttochildiexperience, Modellabelingofemotionandexperi-!ence.: Identifyemotionswhilereading,watch-I;ing television, " ;processesassociatedwithsurvival(eg,rapi dmotoricactivation,arousal)becomepriorit izedoverprocessesas-sociated withhighercognitivefunctions(eg,planning ,organization,inhibitionofresponse).Amon gchildrenexposedtointenseorrepeatedtraum as,theseresponsesarelikelytobetriggeredb yminorstresses,eveninresponsetocuesthat, objectively, donotsignifyactualdanger(vanderKolk,seep age401).Forexample,forchildrenexposedtod omesticviolence,certaintriggers(eg, ,physicaltouch) ,therefore,fre-quentlyrespondtotheworlda sif a , : Affectknowledgeskills,ortheabil-itytoacc uratelyidentifyone'sownfeelings,toconnec tthesefeelingstoexperienceandtoreadtheem otionalcuesofothers; Affectexpressionskills,orthecapac-itytos afelyexpressandcommunicateemotional experience;and Affectmodulationskills,ortheabil-itytore cognizeandadjusttoshiftsinemotionalexper ienceandtoreturntoa , ,sequence, :5 IMAY2005,II', SupportchildrenInself- InvolvechildinplanningforIcare,lifeskill s,etc.

9 ;familyactivities,trips, Createappropriate- Highlightstepstowardaccom-plishmentofgoa ls;identifyandsetsubgoals. Encourage/supportindividualchoices;explo re,discussconsequences. Celebratesuccess. Workwithschooltoreinforceindividualachie vements.: Createmilieuforumsi(bulletinboards,etc.) Yalua~eOutco~i .Identifypastandcurrent ;createpower-'.Uselanguageofchoiceand,bo ok,pride-book, TuneintoandbuildsenseI Buildfutureorientation;engageofpersonali dentity:likes,_childin activeplanningfordislikes,hopes, Supportchildinbuildingrelationships.; Participatein (small-group,etc.). Workwithschoolstafftosupportchildintegra tionintoactivities,peergroups, ~~rtuJ'litiesforConnectionIAssessandbuil d.

10 I .Abilitytoreadcuesofsafety!Idanger.: .Distresstoleranceskills. Identifychildinterestsacrossdomains(eg,p eer,Iacademics,arts). ;build! Encouragechildcontribu-Itionstomilieu,pe ers, , ,forexample, ,emotional, , ,suchasbuildingsecureattachmentrelation- ships,positivepeerrelationships, ,13, ,suchasdevelopmentofpositiveself-concept ,awarenessofinternalstates,realisticasse ssmentofself-competencies, ,suchaslanguagedevelopment,16, ,2D-22andgrowthofexecutivefunctionskills suchasproblem-solving,frustrationtoleran ce,sustainedattention,andabstractrea~on , ,somenotonlysur-vivebutthrive, ,26 Tolearnfromsuchsuccesses,efforthasbeenma detochar-acterizethosequalitiesthatdiffe rentiateresilientchildrenfrommorestress- af-fectedchildrenandtoidentifybothin-ter nal(ie.)