Bethany Christian Services

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Bethany Christian Services

• 75 Offices 30 States 16 Countries

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Primary Services

• Adoptions
• Birth Parent Counseling
• Infant
• Older Special Needs
• International

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Large Offices

• Foster Care
• Out Patient Counseling
• In Home Services
• Refugee Services

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Post Adoption Services

• Wellness programs
• Support Groups
• Specific Outpatient Counseling
• Search Reunion

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Approaches

• Attachment Therapies
• Holding Therapy
• Play Therapy
• Grief/Loss

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Diagnosis

• Reactive Attachment D.O. (R.A.D.)
• Dissociative Identity D.O. (D.I.D.)
• Adjustment Disorders
• ADHD

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Issues Diagnosis/Approaches

• Poor prognosis/little hope
• Long Term with slow progress
• Problem/Crisis Focus
• Behavioral Focused

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Trauma Alters Brain Pathways

• Low Road
• High Road

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Trauma Memory

• The stress hormones and neurotransmitters that
  permeate the brains ability to encode new
  memories and simultaneously interfere with its
  ability to sequence and contextualize those
  memories.

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Traumatic Memories

• Have tunnel vision
• Have lost peripheral detail
• Are fragmented and sensory
• Are encoded as disconnected fragments
• And are triggered by unforeseen cues

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Traumatic Memories

• Are not the consequence of conscious choice or
  resistance. They are the consequence of the
  radically altered neuro chemical environment in
  which the memories were encoded.

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Trauma Leaves

• Brain permanently altered
• Legacy of fear networks that are etched in brain
  (Amygdala) that can be triggered by a multitude
  of cues that would not ordinarily evoke fear.
• Fragmented and discontinuous memories of what
  happened.

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Trauma Is

• A traumatic or life-threatening event that is
  outside the normal range of daily human
  experience.
• It arises when adult/children experience or
  witness such an event
• These events confront people with such horror and
  threat that it may temporarily or permanently
  alter their capacity to cope, their perception of
  biological threat and their self-concepts.

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Traumatic Events

• Sexual Abuse
• Life-threatening injury/illness
• Violence (family, social, predatory)
• Terrorism
• Natural or other disasters (hurricane,
  earthquake, fire)
• Parental Substance Abuse

• Rape/Assaults
• Murder
• Threaten with a weapon
• War
• Early loss of parent
• Neglect
• Physical Abuse
• Emotional Abuse
• Vicarious/Secondary Trauma

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Acute

• Normal response to a single or single episode of
  trauma response involves intense fear,
  helplessness or horror.
• Symptoms include
• Numbing / detachment / lack of emotional
  responsiveness
• Being in a daze
• Depersonalization
• Dissociative amnesia
• Traumatic event re-experienced through recurrent
  images, dreams, illusions and flashbacks
• Avoidance of stimuli that arouse recall of
  traumatic thoughts, feelings, etc
• Medical symptoms of anxiety increased arousal
  (difficulty sleeping, irritability, poor
  concentration, hyper vigilance, exaggerated
  startle response and motor restlessness

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Post Traumatic Stress Disorder

• Can occur in childhood, adolescence, or
  adulthood.
• May become apparent immediately or be delayed
  until adulthood
• May involve both psychological and physical
  symptoms
• Often occurs along with other conditions like
  depression, substance abuse, memory and thinking
  problems

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3 Major Characteristics of PTSD

1. Repeated reliving of memories of the traumatic
   experience
2. Avoidance of reminders of the trauma, and the
   numbing, detachment and emotional blunting that
   often coexist with intrusive recollections
3. Patterns of increased arousal (hyper arousal)
   expressed by hyper vigilance, irritability,
   memory concentration problems, sleep
   disturbances and an exaggerated startle response

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Symptoms

• Confusion
• Agitation
• Fear/Anxiety
• Anger/Irritability
• Feeling of helplessness
• Fear of imminent death
• Inability to concentrate

• Shock / apathy/ numbness
• Disassociation
• Withdrawal/ detachment
• Flashbacks
• Sleep disturbances
• Physical symptoms
• Decrease interest in lifes activities

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Why Do Some Develop PTSD While Other Dont?

• Nature extent of trauma
• Coping skills
• Previous experiences
• Current stress levels
• Support system
• Family social environment
• Biology / brain

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Complex Trauma / PTSD(Disorders of Extreme
Stress)

• Majority of children/adults who seek treatment
  for trauma related issues have histories of
  multiple traumas
• They seek treatment not because of PTSD symptoms
  but related to their depression, anger outbursts,
  self destructive behaviors, feelings of shame,
  self blame and distrust

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Symptoms Associated with Early Complex
Interpersonal Trauma (B. Vanderkolk)

1. Alterations in the regulation of affective
   impulses, including difficulty with modulation of
   anger and being self destructive
2. Alterations in attention and consciousness,
   leading to amnesias, dissociation and
   depersonalization episodes
3. Alterations in self perception, such as a chronic
   sense of guilt and responsibility, and
   chronically feeling ashamed

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Symptoms Associated with Early Complex
Interpersonal Trauma (B. Vanderkolk) cont

• 4. Alterations in relationships with others,
  such as not being able to trust and not being
  able to feel intimate with people,
• Somatization of the problem feeling symptoms on
  a somatic level, when medical explanations cannot
  be found,
• Alterations in systems of meaning.

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Impact of Trauma on Child Development

• To understand how trauma affects children, it is
  important to understand children from a
  developmental context.
• When a child experiences a traumatic event or a
  series of traumas, a great amount of emotional
  and mental energy is expended to process the
  event and what it means in their world.
• This may reduce the childs capacity to explore
  and gain mastery over age appropriate
  developmental tasks.
• NCTSN The National Child Traumatic Stress Network

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Impact of Trauma on Child Development

• As trauma goes untreated, children tend to stray
  further and further away from appropriate
  developmental paths. The consequences of chronic
  exposure to maltreatment can include social
  inadequacy and increasingly disruptive behavior,
  resulting in interventions becoming more punitive
  in nature.
• Following is information about how children
  respond to trauma at different developmental
  stages. (adapted from Pynoos Nader Marans)
• NCTSN The national Child Traumatic Stress Network

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Complex TraumaArea 1 Attachment

• Uncertainty about the reliability and
  predictability of the world
• Problems with boundaries
• Distrust and suspiciousness
• Social isolation
• Difficulty relating to others
• Difficulty empathizing
• Source Complex Trauma White Paper
  published by the NCTSN
• NCTSN The National Child Traumatic Stress Network

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Complex Trauma Area 2 Biology

• Hypersensitivity to physical contact
• Problems with coordination, balance, body tone
• Delayed sensory and motor development
• Somatic complaints and increased medical problems
  (e.g. asthma, skin problems, autoimmune
  disorders)
• NCTSN The National Child Traumatic Stress Network

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Complex TraumaArea 3 Affect Regulation

• Difficulty with emotional self-regulation
• Difficulty describing feelings and internal
  experience
• Problems knowing and describing internal states
• Difficulty communicating wishes and desires
• NCTSN The National Child Traumatic Stress Network

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Complex TraumaArea 4 Dissociation

• Withdrawing attention from the outside world
• A detached feeling as if one is observing
  something happen or as if it is unreal.
• When fleeing or fighting is not physically
  possible, a child may psychologically flee
• Amnesia
• NCTSN The National Child Traumatic Stress Network

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Complex Trauma Area 5 Behavioral Control

• Poor impulse control
• Aggression against self or others
• Pathological self-soothing behaviors
• Disturbances in sleeping or eating
• Substance abuse
• Excessive compliance or oppositional behavior
• Difficulty understanding and complying with rules
• Communicating past trauma by reenactment in
  behavior or play (sexual, aggressive, etc.)
• NCTSN The National Child Traumatic Stress Network

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Complex TraumaArea 6 Cognition

• Lack of sustained curiosity
• Problems focusing on and completing tasks
• Difficulty planning and anticipating
• Problems understanding own contribution to what
  happens to them
• Learning difficulties
• Problems with language development
• NCTSN The National Child Traumatic Stress Network

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Complex TraumaArea 7 Self-Concept

• Lack of continuous, predictable sense of self
• Poor sense of separateness
• Disturbances of body image
• Low self-esteem
• Shame and guilt
• NCTSN The National Child Traumatic Stress Network

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The Brain
Amygdala smoke detector /signals release of
hormones Cortex thinking processing
reasoning Limbic system doing responding
action Hippocampus assists in transfer of
information Stress hormones suppress the hippo
activity thus information doesnt make it to
the cortex to rationally process
cortex
Limbic system
amygdala
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Patterns of Reacting Responding

• Fight
• Hyperarousal
• Aggression
• Trouble concentrating
• Irritability
• Anger
• Hyperactive
• Flight
• Withdrawal
• Avoidance
• Isolation
• Running away
• Freeze
• Constriction/shutting down
• Numbing
• Spacey, zoning out
• Daydreaming
• overcompliance

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Triggers

• Any stimulus which acts as a reminder of a
  traumatic experience, and leads to a set of
  behaviors/actions designed to cope with the
  original experience
• A trigger may be
• Internal (emotion, physical sensation)
• External (facial expressions, crowds, smells,
  sounds)
• A combination
• Blaustein and Kinniburgh 2004

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Triggers

• Key Triggers
• Lack of power or control
• Unexpected change
• Feeling threatened or attacked
• Feeling vulnerable or frightened
• Responses to triggers
• To seek safety avoid danger
• Blaustein Kinniburgh 2004

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Neuroscience of Cognitive Behavioral Therapy

• Neural growth and integration are enhanced by
• Activation of neural networks that are
  inadequately integrated
• Moderate levels of stress alternating with
  periods of calm and safety
• Integration of conceptual knowledge with
  emotional and body experience through narratives
  that are co-constructed with the therapist

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Top-Down Integration

• Circuits form loops that go from the top of our
  brain to the bottom and back again
• Includes the ability of the cortex to process,
  inhibit, and organize reflexes, impulses and
  emotions generated by the brain stem and limbic
  system
• Frontal lobe disorders like ADHD and OCD
• Disinhibition of impulse and movements normally
  under control

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Left-Right Integration

• Allows us to put feelings into words
• Bring feelings into conscious awareness
• Balance left and right hemisphere biases
• Left-more closely identified with cortical
  (intellectual) functions
• Right-more connected to the body via brainstem
  and limbic functions

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Cortical Integration

• Frontal Cortex (Executive Function)
• Mediates the integration of top-down and
  left-right interaction
• Integration is accomplished by
• Simultaneous or alternating activation of
  conscious language production (top and left)
  with the more primitive, emotional and
  unconscious processes (down and right) that
  have been dissociated due to undue stress
  during childhood or trauma later in life
  (Siegal, 1999)

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Cortical Integration

• Research across most forms of therapy supports
  the hypothesis that positive outcomes in
  psychotherapy are related to the combined
  engagement of thought and affect, utilizing both
  support and challenge. (Orlinsky Howard, 1986)

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Telling YOUR Story

• Autobiographical memories are at the core of our
  sense of self
• Storytelling weaves together body sensations,
  feelings, thoughts and behaviors
• Stories provide an opportunity for
  self-reflection

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Telling YOUR Story

• Stories provide an opportunity to learn things
  about yourself you did not know
• Understanding YOUR story can help make you a
  better person and break multigenerational
  patterns of disorganized attachment

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Results of Being Able to Tell YOUR Story

• No longer have to relive it
• It happened when I was.

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The impacts

• The traumatized child develops alterations in
  ones system of meaning
• all touch is bad, people let you down, nighttime
  is scary

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The ADOPTS ProgramTrauma-informed therapy for
pre and post adoptive children

• Jeremy C. Moore, MPA
• ADOPTS Coordinator

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ADOPTS Program

• October 2004 4 year ACF grant
• 600 Children to be served (230 served to date)
• Currently operating in 5 offices in Michigan
• Expanding to Georgia, Iowa, Tennessee,
  Pennsylvania and Washington in 2007

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ADOPTS Goals

• Reduce adoption disruption rates among children
  compared to other forms of post-adoption services
• 75 of children completing program will reduce
  PTSD symptoms directly after completion of
  ADOPTS, and 50 will sustain these gains for 1
  year.
• Disseminate family education resources to
  adoptive families
• Develop specialty-response adaptations of ADOPTS
  model

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Who does ADOPTS serve?

• Children in pre or post adoptive situations such
  as pre-adoptive home, adoptive home, kinship
  placement, permanent or temporary foster care,
  residential
• 75 of children served between 8 16 years of
  age
• 80 of children have been in 1-4 total placements

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ADOPTS Client Demographics Chart
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ADOPTS Client Demographics Numerical

• Race Demographics
• 50 Caucasian
• 16 African American
• 13 Eastern European adoptions
• 8 Biracial
• 5 Asian or South/Central American adoptions
• 4 Hispanic

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ADOPTS client exposure to trauma Percent
n233
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ADOPTS Clinical foundations
ARC
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The ARC Model

• The backdoor approach to attachment
• Addressing the trauma experiences of the child as
  primary focus
• Attachment as secondary

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The ARC Model

• Attachment
• Building safety
• Caregiver management of affect and attunement
• Praise and reinforcement
• Regulatory Capacities
• Affect identification and management and
  expression
• Competencies
• Mastery of management tools
• Practicing connection
• Promoting self-efficacy

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A is forAttachment

• Overarching goal (re-)creation of a safe
  environment that supports healthy development,
  and building of new working models of self and
  other
• What does attachment do in normative development?
• Allows children safety to explore their world
  (agency)
• Provides healthy model of self and others (trust)
• Teaches child how to communicate, and how to read
  others communication
• Teaches children how to understand, tolerate and
  cope with emotional experience
• Provides structure and limits
• Attachment both contains and opens up the childs
  world

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R is for.Self-Regulation

• Overarching goal Helping children develop the
  skills needed for healthy regulation of self
  emotions, behaviors, experience, relationships,
  physiology
• Disrupted attachments and overwhelming stress
  derail the normative processes by which children
  develop these skills
• Treatment targets both child strategies, and
  adult techniques for supporting those strategies

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C is forCompetency

• Overarching goal Helping children build all of
  the individual strengths and skills that help
  them navigate their life
• The goal of therapy is not just to fill the
  cracksits to build or re-build the foundation
• Competency may include
• Problem-solving skills, social skills, identity,
  future orientation, academic motivation,
  independence and responsibility
• Make space for resiliency help children learn to
  be children
• It is essential to build experiences of joy and
  success

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ADOPTS Clinical foundations
ADOPTS
ARC
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The ADOPTS Program

• Trauma therapy for adoptive children and their
  parents
• Addressing Post Traumatic Stress Complex Trauma
• Trauma Assessment
• 16 weeks of individual therapy
• 6 weeks of parent groups
• 6 weeks of child groups

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ADOPTS Model Structure Assessment

• CAPS or TSCYC Evaluation Session
• Parent Intake Session

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ADOPTS Model Structure Individual

• 16 sessions with child parents together
• Sessions focus on
• Psychoed
• Building safety
• Modulation
• Competency
• Follow-up

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ADOPTS Model Structure Groups

• Adolescent sessions focus
• Skills
• Experiential
• Identity
• Parent sessions focus
• Psychoed
• Support
• Skills

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ADOPTS Evaluation Methodology

• Pre and Post Evaluations of
• Traumatization (CAPS CA and TSCC)
• Parent stress (PSI)
• Child behavior (BASC)
• 12 month evaluations of
• Questionnaire
• Traumatization (TSCC)
• Parent stress (PSI)
• Child behavior (BASC)
• Stand alone
• Parent feedback
• Child feedback
• Group feedback

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ADOPTS Outputs

• 10 ADOPTS sites in 6 states 2007
• 230 children served
• Over 1,000 parents and professionals trained on
  trauma
• Online application process web resources at
  www.bethany.org keyword ADOPTS
• Program manual (currently under revision)

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ADOPTS OutcomesCAPS CApre and post n109
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ADOPTS OutcomesTraumatization (TSCC t
scores)pre and post n112
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ADOPTS OutcomesTraumatization (TSCC t scores)
Clinical sig. n8
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ADOPTS OutcomesChild Behavior BASC n109
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ADOPTS OutcomesParent Stress PSI n125
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ADOPTS Outcomes

• 88 (14/16) of adoptions remain intact at
  12-months after program exit.
• 97 of parents indicated they had more confidence
  in parenting their child after the parent group
• 90 of children indicated they are doing OK to
  great at getting along with their family at
  closing
• 94 of parents indicated their parenting skills
  improved because of ADOPTS

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Testamonials Parents

• I think (this program) is pinpoint perfect as
  far as identifying where these kids are and
  helping them move forward. They didnt choose to
  be abandoned its not their fault. We have to
  find a way to get them in the best possible
  situation. This is the first time Ive felt that
  hes going to get there.
• ADOPTS Parent

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Testimonial Parents

• We are definitely more into being in tune with
  kids' feelings and what is going on with them.
• It was nice to be with other families going
  through the same thing.
• The program is unique and is a perfect
  steppingstone for children to begin to
  heal.
• Adoptive Parents

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Testimonials Children

• I learned to communicate better. I actually talk
  to my parents. It's a miracle.
• I'm not arguing as muchI'm not fighting a lotI
  don't throw so many fits.
• I learned to use my toolbox and take deep
  breaths. I learned what to do with my worries.
• Adopted Children

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The future lessons learned

• Professional parent ed.
• Factors related to child response to treatment
• The importance of tune ups
• 16 weeks v. long-term model
• Model development needs
• Child adaptation with SI focus
• Need for foster care adaptation
• Gender specific development of interventions
• Impact on International Adoption children