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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 rebecca_wild@health.qld.gov.au
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
Principles of Treatment
What helps them heal?
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
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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
Principles of Treatment
What helps them heal?
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
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
What helps them heal?
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
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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?
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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:
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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.
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
Formulation
Child – including diagnosis & risk assessment
Identified strengths & barriers in system.
Collaboration
Treatment Plan
Concurrently stabilising
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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 rebecca_wild@health.qld.gov.au
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?
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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 rebecca_wild@health.qld.gov.au
Stabilising
7. Reduce Arousal
(all of the above will do this) also consider:
Exercise
Relaxation
Mindfulness
Sleep hygiene
Medication
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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.
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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?
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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.
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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.
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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?
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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.
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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.
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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.
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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:
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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
resilience and resources,
self esteem and identity
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.
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
resilience and resources,
self esteem and identity
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.
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
Important treatment Foci-
Important Foci that might need weaving through treatment
Placement Breakdown
Sexual Boundaries
Cultural connectedness
Aggression
Substance Abuse
23/06/13 Dr Rebecca Wild 2013 rebecca_wild@health.qld.gov.au
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