Dr. Rebecca Wild, Royal Australian and New Zealand College of Psychiatrists Queensland Branch - Impact of cumulative harm and the options for supporting recovery

CHILD PROTECTION CONFERENCE SYDNEY 2013

Dr. Rebecca Wild

Child Psychiatrist

Working together to help children heal: what does it take?….

Child Protection ….Why focus on

healing?

neglect and abuse cause harm.

This harm can be Profound

Resilience is not inexhaustible.

These children do get better with

appropriate support.

Cumulative harm

‘The effects of multiple adverse or harmful circumstances and events ‘Miller and Bromfield 2010

Acts of both commission and omission.

A crucial concept in a child protection framework, often associated with the concept of sub-threshold harms in risk assessment.

What does it mean in a therapeutic frame?

Children are shaped by experience, multiple experiences are powerful.

Neurons that fire together wire together.

What Frameworks. Help us to

think about these experiences?

Trauma (Complex / Type Two)

Attachment ( disrupted)

Periods of Environmental Deprivation/Toxicity

Developmental Delay ( developmental windows)

Neurobiology

Serial Loss and Disenfranchised Grief

Complex Trauma

Type two

Also consider relational, intentional, role of primary

attachment figure.

Pre-verbal

Impacts of Complex Trauma (Cook etal and van der Kolk 2005)

Attachment and Interpersonal difficulties (ASD)

Biology (developmental disorders PDD NOS, physical

illness)

Affect Regulation (BPAD)

Dissociation (anxiety dx, ADHD)

Behavioural Control (ODD,CD)

Cognition ( II and LD, FASD)

Diagnosis

Meeting criteria is necessary but not sufficient

Diagnosis incorporates context

Checklists and screening instruments are tools only.

Developmental trajectory

0 2 5 10 15 20 25

normative

reparative

compound trauma noreparation

unconsolidatedreparative care

Therapeutic interventions for

children in care

Promote psychological recovery from the effects of complex trauma and disrupted attachment

Support children to move towards a developmental trajectory that reflects their potential

Build resilience in them and their systems so that they can maintain recovery.

23/06/13 Dr Rebecca Wild 2013 [email protected]

Principles of Treatment

What helps them heal?

Prevent or reduce further cumulative harm.

Thorough assessment and individualised therapeutic intervention

WHY IS QUALITY ASSESSMENT

IMPORTANT ?

Risk of inappropriate diagnosis ( trauma the

masquerader). Lumbering with inaccurate labels that

stop us thinking.

Risk of missing comorbidity

Risk of treating the paradigm not the child.

Importance of diagnosis and formulation to evidence

based targeted treatment including medication.

Importance of knowing this child’s history, strengths,

triggers etc.

Importance of Assessment

Basis for identity and life story work

Identifies missing pieces in the community puzzle eg. Kinship carers, potential for building networks.

Shared with care team makes the child and their behaviour explicable

Prepares the treatment team to give informed opinion to care team about casework..contact…reunification…education etc. decisions

It is containing for the child for someone to know



Prevent or reduce further cumulative harm.

Thorough assessment and individualised therapeutic intervention

Staged interventions and thoughtful assessment re. readiness for each intervention

Therapeutic Needs of Children in

Care

Pyramid of Need

FEELING SAFE

PHYSICALLY AND EMOTIONALLY

DEVELOPING RELATIONSHIPS

COMFORT AND CO-REGULATION

ELICITING CARE FROM RELATIONSHIPS

EMPATHY AND REFLECTION MANAGING BEHAVIOUR

IN RELATION TO OTHERS

RESILIENCE AND

RESOURCES

SELF-ESTEEM AND IDENTITY

EXPLORE TRAUMA,

MOURN

LOSSES

A hierarchy of needs. Assess where child is to guide choice of interventions.

Children move up and down in response to current circumstances.

Kim Golding 2007


RESILIENCE Attachments & connections

Cognitive capacity

Capacity to self-regulate

Mastery and autonomy

Effective coping

Positive self beliefs

Creativity

Spirituality

Being easy going

Having a positive temperament



Collaborative cohesive care team inclusive of with strong liaison relationships with decision makers. ( cultural consultation)

Multimodal: multiple problems, multiple solutions

Intensive and global :Injury sustained over multiple occasions across multiple domains requires multiple reparative experiences across multiple domains ( Perry)

Reparative care across all domains, repetitive corrective experience

SCHOOL

Teacher aide

Teacher

Admin

Peers

CSO CHILD SAFETY TEAM

CSSO

MOTHER

Step Father

Respite family

Extended kin

Respite family 2

Father

RELATIONSHIPS Therapy

team

Surf club Extended

foster family

CHILD

Foster parents

(siblings)

Siblings (monthly contact)

Foster siblings

Foster mum

Foster father

Supporting Systems

Anxiety generated by child’s behaviour.

Legislative or resourcing limitations.

Stakeholder splits:

Different frameworks/expertise

Special connection

Perceived devaluing

Territoriality and funding

Don’t feel invested in process

Child overwhelms capacity despite support offered


Consider the Therapy Team

Does the therapist have a place to reflect and regroup,

good supervision, leadership, a supportive team.

Is the care integrated: assessment including ( diagnosis,

developmental, IQ, speech, OT) psychosocial

interventions, psychopharmacology

Multidisciplinary teams, psychiatric leadership.

Role of developmental pediatricians?

Helping them Heal :Trauma

informed

Trauma is a bodied experience, physiological and affective regulation

felt safety, co-regulation and capacity building

TFCBT principles

-parenting and psychoeducation

- cognitive restructure,

- repeated exposure with affective regulation,

- creation of narrative.

trauma treatment

Chronic hyperarousal

Developmental delay

Need for co-regulation

Unconscious …… rather than conscious identifiable experiences

Pre-verbal

Cognitive and language difficulties

Safety

Affect regulation takes longer

Mutiplicity of traumas



Attachment

Attachment informed : attuned reflective consistent care, continuity of primary carer or care group. SECURE BASE.

Disrupted attachment>Disorganised 75% >RAD and DAD

Bowlby >Circle of Security

Environmental enrichment to reverse developmental delays

aaa


Relational focus ( attachment and resilience) including relationships that foster cultural engagement.

Community connectedness (family of origin, family of care, identification and fostering of cultural connections, peers, school, CSO, other stakeholders

Identity and life narrative (this can be an avenue for children who are disconnected from cultural and kinship connections to explore and rebuild) Life Story Therapy Richard Rose.

Helping them heal


END

Phase One: Assess & Stabilise Secure Base . Felt Safety

Assessment

Who is this child?

What challenges do they face?

What strengths do they bring?

How did they get to this place?

Who can support them?

What knowledge or wisdom do they hold about

this child? – what questions?

What resources do they have?


System – each stakeholder holds individually

& as part of an organisation:

Beliefs about the child

Beliefs about children

Unconscious internal working models based on their own

attachment history or experience as

parents/professionals

Knowledge about the impact of trauma and disrupted

attachment

Skills in supporting children or areas that they want to

build skill


Systemic Work

Best evidence base of all is for collaboration

Need to influence all domains to provide enough reparative experiences

Adults working together to hold the child

What is the system?

Who knows the child?

Who makes the decisions?

How do they communicate?

SCHOOL

Teacher aide

Teacher

Admin

Peers

CSO CHILD SAFETY TEAM

CSSO

MOTHER

Step Father

Respite family

Extended kin

Respite family 2

Father

RELATIONSHIPS Therapy

team

Surf club Extended

foster family

CHILD

Foster parents

(siblings)

Siblings (monthly contact)

Foster siblings

Foster mum

Foster father

Frameworks / beliefs / priorities e.g. children need

to be met where they are developmentally or

children need to be supported to be independent

Specific insights into the child or specific skills they

can share with the group

Beliefs about group dynamics

System – each stakeholder holds individually

& as part of an organisation:


System

Assessing the child will necessarily involve thinking about what each stakeholder brings to and needs from the system – the extent of this enquiry depends on closeness to the child and the invitation offered.

E.g.. A school might request education sessions for the staff body and weekly support for the teacher or, be prefer to use internal resources.

A carer might want to use an adult attachment interview to reflect on why this particular child triggers them or may prefer to focus on strategies….

therapist might take similar themes to supervision.


System

Stakeholder Group:

how does the group collaborate?

Does the clinician need to work with the CSO

to support the collaborative process?

Organisational fit:

Clear boundaries & responsibilities

Role clarification

Open communication around philosophical

difference


System

Stakeholder Group:

how does the group collaborate?

Does the clinician need to work with the CSO

to support the collaborative process?

Organisational fit:

Clear boundaries & responsibilities

Role clarification

Open communication around philosophical

difference


Formulation

Child – including diagnosis & risk assessment

Identified strengths & barriers in system.

Collaboration

Treatment Plan

Concurrently stabilising


Stabilising

1. Identify priorities for intervention e.g.. Aggression

or sexualised behaviour (map risks with

stakeholders, risk assessment and interim

management planning)

2. Identify and treat acute illness e.g. psychosis

3. Support collaboration Set parameters

Is everyone in agreement about acute

priorities and management?

Do case manager & CSO need to actively

support collaboration – identify barriers and

manage them,

Communication strategies 23/06/13 Dr Rebecca Wild 2013 [email protected]

Stabilising

4. Map appropriate support and supervision for

child across settings

(communication across settings)

5. Identify & manage acute stressors

precipitants, triggers:

- does contact need to be more supported?

- Is there a bully at school?


Stabilising

6. Promote felt safety

• Clear predictable boundaries and routines (including nurture)

• Clearly identified safe supportive adults e.g. Regular respite

carer; one aide at school

• Support adults to co-regulate child when distressed / identify

signs / know how to intervene

• Healthy touch

• Sensory profile and tools

• Predictable, logical, fair consequences for infringing rights of

others. 23/06/13 Dr Rebecca Wild 2013 [email protected]

Stabilising

7. Reduce Arousal

(all of the above will do this) also consider:

Exercise

Relaxation

Mindfulness

Sleep hygiene

Medication


8. Promote Self Efficacy and Esteem

Avoid false praise

Identify genuine strengths –praise and open

opportunities

Look for mastery opportunities

Positively reinforce whenever authentically

indicated- “well done, you managed your

disappointment really well then..”

Baby Steps and Realistic Goals


Stabilising

9. Advertise safety and connection

Regular contact with powerful decision makers; CSO, School Principal:

they know you.

they are looking out for you.

Good communication – two way.

Social stories.


Stabilising

Contact with biological family:

Can this be safer, more predictable, more supported?

Can we identify siblings, Grandparents etc who have good capacity to meet some of child’s needs?

Rules at resi / school / care, are to keep everyone safe....

Give child a voice but don’t make them responsible for adult decisions.

Are all decisions being made with the child’s need for stability, predictability and consistency of relationship in mind?


stabilising

10. Identify important relationships and prioritise them

Support these adults to be safe, consistent, available, non-shaming

Use of PACE principles (Hughes)

PLAYFUL

ACCEPTANCE

CURIOUS

EMPATHIC


stabilising

Psycho-education and regular sessions help carers and other stakeholders process these themes from the week before are offered

Focus on ideas from: CIRCLE OF SECURITY – secure base from which to

explore Bigger Stronger Kinder Wiser; issues of cuing and attunement

KIM GOLDING – see Pyramid of need

DAN HUGHES - PACE

TRAUMA FOCUSSED CBT - psycho-education re impact of trauma; parenting the traumatised child; the traumatised child’s beliefs.


developing relationships

Therapeutic alliance – child tolerating

consistency, positive regard, flexible

engagement.

Therapy remains very flexible; may be activity

based; may include structured psycho-ed e.g..

Safe touch. Themes reinforced by Care Team.

Biological parent may be being supported and

scaffolded by therapist and Care Team to

maintain safe connection.


barriers

Can these issues be:

Worked through in the care team

Worked through with external facilitation or

support?

Taken back to clinical team?

Worked through at Senior Interagency level?


therapeutic needs of children in care

Pyramid of Need

FEELING SAFE

PHYSICALLY AND EMOTIONALLY

DEVELOPING RELATIONSHIPS

COMFORT AND CO-REGULATION

ELICITING CARE FROM RELATIONSHIPS

EMPATHY AND REFLECTION MANAGING BEHAVIOUR

IN RELATION TO OTHERS

RESILIENCE AND

RESOURCES

SELF-ESTEEM AND IDENTITY

EXPLORE TRAUMA,

MOURN

LOSSES

A hierarchy of needs. Assess where child is to guide choice of interventions.

Children move up and down in response to current circumstances.

Kim Golding 2007


comfort & co-regulation

therapist supporting care team especially foster carer/key worker (school may use modified technique) with:

Singing.

Safe touch – massage / hugs.

Nurture – sensory modulation / aromatherapy

/ rocking etc.

Praise.

Talking for; scaffolding; identification of feeling states and monitoring de-escalation of arousal.

Playfulness – cycles of arousal and de-escalation; may draw on Theraplay.


comfort & co-regulation

Time In

Therapy – focus on nurturing activities, e.g.. Cooking.

Accepting care (processing discomfort).

Mindfulness

Relaxation

Self-soothing

Share language for feelings


empathy & reflection

Modulation of shame – since beginning Care Team have been modulating shame invivo

Externalising problems so they can be owned

Clear boundaries & consequences modelling concern for child & others

Remediation when harm others (remediative justice & reparation)

Positive regard for child. Opportunities & scaffolding to rupture & repair relationships.


empathy & reflection

Gradual building opportunities to develop empathy.

Modelling at school & home of reflective functioning

Mindfulness / mentalization – awareness of the minds of others invivo. I wonder why…? what X is feeling….?

Therapist models and supports this process – may use DDP or individual therapy to help child reflect on incidents

May actively support reparation

Use of social stories / narrative practices.


resilience and resources,

self esteem and identity

1. Resilience

Therapist has been supporting Care Team to build resilience throughout treatment. At this stage we can review, regroup consider whether we have used all the tools we have

Looking at the evidence in the general population:


RESILIENCE Attachments & connections

Cognitive capacity

Capacity to self-regulate

Mastery and autonomy

Effective coping

Positive self beliefs

Creativity

Spirituality

Being easy going

Having a positive temperament



Important to consolidate this in treatment planning

Are learning & mastery experiences being optimized?

Positive psychology principles can be integrated into systems approach and individual therapy – as child heals and moves away from position of shame to int. locus of control.




Identity –

Where do I come from?

Who are my family?

Who am I / What can I be?

What does it mean to be in care?

Invivo – opportunities at contact etc.

Social stories / dyadic and individual therapy.

Life Story work.


explore trauma, mourn losses

Child may have brought these themes piecemeal to

trusted adults already

Therapist will have supported them to help child

process at own pace –

Now child has resources to better cope –

May be able to explore these themes in more

depth –

Given opportunity in individual therapy or

dyadically


what is missing in conventional

trauma treatment?

Relationship ) Object relations

Co-regulation / comfort ) &

Empathy ) Attachment

Most are CBT

Can we elicit cognitions –yes but it may be invivo, via trusted adults

co-regulation prior to self-regulation


explore trauma and mourn losses

Life Story work, identified losses and grief,

narrative, celebrate gains and past joys

Psychodynamic

Expressive

DDP – supported by attachment figure

TFCBT parenting and psychoed, cognitive

restructure, repeated exposure with affective

regulation, creation of narrative


Important treatment Foci-

Important Foci that might need weaving through treatment

Placement Breakdown

Sexual Boundaries

Cultural connectedness

Aggression

Substance Abuse


Health & Medicine

Dr. Rebecca Wild, Royal Australian and New Zealand College of Psychiatrists Queensland Branch - Impact of cumulative harm and the options for supporting recovery