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.,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 !]

2 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." ,impairedattachmenthasbeenlinked10multip lenegativeout-comes, ,inconsistency,orunpredictability;multip leseparationsduetoout-of-homeplacementor caregiverhospitalization, ; ,neglectful,orrejectingcare-givingis forcedtomanageoverwhelmingexperiencesbyr elyingonprimitiveandfrequentlyinadequate copingskillssucha~ , , :building(orrebuilding)healthyattachment sbetweenthosechildrenwhohaveexperiencedt raumaandtheirt.)

3 :aregivers; : Creatinga structuredandpredictableenvironmentbyest ablishingritualsandroutine:PSYCHIATRICAN NALS35:5 IMAY2005 IndividualRoutines&Rituals Workwithchildtobuilddailypatterns. Havepredictabletherapyroutines. " "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.

4 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).)

5 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). (eg,"TurnIuptheVolume,"big/smallmovement s,iyoga/dance/martialarts). Buildforumsforregularcommunication:writt en,residentmeetings; Usereflectivelisteningskills. Modellabeling.

6 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.). 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).

7 Amongchildrenexposedtointenseorrepeatedt raumas,theseresponsesarelikelytobetrigge redbyminorstresses,eveninresponsetocuest hat,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.;familyactivities,trips, Createappropriate- Highlightstepstowardaccom-plishmentofgoa ls;identifyandsetsubgoals.

8 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:.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,temperament,perceivedcom-petence, self -worth)andexternal(ie,family,communi ty) [oslerdevelopmentalcom-petencies(eg,plan ning, )andfamilialandsystemicresources(eg,care giversupport,con-nectionswithteachers,us eofmentors).]

9 Interventionalsoshouldfocusontwobroadgoa ls:thebuilding(orrebuilding)ofnormativec ompetenciesthathavebe-comederailed;andth eestablishmentofexternalresourcesthatcan supporta re-silientoutcome,Thesegoalsareachievedt hroughafocusonfourgeneralprinciples,Firs t, ,createopportunitiesforconnectiontopeers , ,identifyandbuildona child' ,encouragepracticeandteachthechildtoeval uateoutcomesinorderto fos-tcra , thereforeiscrucialtoidentifydevelopmenta lstatusaswellaspre-existingindividual, ,multiplemo-dalitiesandsampleactivitiesm aybeused(Table3,seepage429), flexibleapproachtoin-tervention,ARChasbe endevelopedinresponsetothischallengesasa ninter-ventionframeworkdesignedtoaddress 430thearrayofdevelopmentalvulnerabili-ti esexperiencedbythecomplexlytrau-matizedc hildbybuildingorrestoringdevelopmentalco mpetencies,identify-ingandenhancinginter nal,familial,andsystemicresources, ,BlausteinM,SpinazzolaJ,vanderKolkB, , : !

10 Nctsn_assets/pdfs/edu_ , ;64(2):237-243, , :AnthonyEJ,CohlerB, :TheGuilfordPress,1987 ,CrittendenPM, :GoldbergS,MuirR,KerrJ, ,NY:AnalyticPress;1995 ,WakschlagL, ,Del' ;35(2):569-579, ,AtkinsonL, 'speerrela-tions:aquantitativereview,Del ' ;37(1) ,CarlsonV,CicchettiD,BarnettD, ' ;25(4) , ,In:OsofskyJ, :InterventionandTrem-mellt, :TheGuilfordPress;2004 ;:,edChildren:HealingFroml. Jsses,Violence,Abuse, ,NY:HaworthMaltreatmentandTraumaPress; ,PelcovitzD,KaplanS, ~Respond-ingtoChronicStress(SPARCS). , , (PTSD) '\'. ,KoenenK,CohenL, :apha~ " ;70(5) , ' :3(4) , ;23(11) , , attachment , 'Psychol' ;6 , , !.1990;14(4) , ;6()121 ,WatkinsR, 'slanguageandspeechdevel-opment:allu' , ;11(33Pt3) ,' '182;6(3) , ,Maltreatment,com-petencydeficits, ' ;37(1) ,TrickettP,McBride-ChangC, ' ;6 , , ;102(2) , :159(3) , :42(8):I ,SmithRS,JourneysjivrnChild-hood10 Mid'ife:Risk, , !w!.1998;53(2) :5 IMAY2005 CopyrightofPsychiatricAnnalsisthepropert yofSLACKI ncorporatedanditscontentmaynotbecopiedor emailedtomultiplesitesorpostedtoa ,usersmayprint,download,oremailarticlesf orindividualuse.