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Basics of Traumagenic Family problems

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  1. 1. The impact of developmental trauma in the lives of children and those that care for them . Dr. Robert Rhoton PsyD [email_address]
  2. 2. Dr. Robert Rhoton PsyD (Brief Bio) <ul><li>College teacher since 1994 </li></ul><ul><li>Chair of Marriage and Family Therapy at Ottawa University </li></ul><ul><li>President of the Arizona Trauma Network </li></ul><ul><li>Author </li></ul><ul><li>Grandpa of 8 </li></ul>
  3. 3. Overview of presentation: <ul><li>Basic biology of neurodevelopment in children. </li></ul><ul><li>How dysregulation creates patterns of perception, experience, behavior and meaning </li></ul><ul><li>Adverse childhood experiences </li></ul><ul><li>Family dynamic environments and associated behaviors </li></ul><ul><li>What to do? </li></ul>
  4. 4. Brain development Use dependant development <ul><li>the more any neural system is activated the more a neural system changes </li></ul><ul><li>piano:- hear - visual - motor </li></ul><ul><li>speech:- auditory - understand - motor </li></ul><ul><li>written word - seen - thought about - spoken </li></ul>
  5. 5. Brain Stem
  6. 6. Brain Stem <ul><li>The Brainstem is the first region of the brain to develop before birth. Directly connected to the spinal cord. </li></ul><ul><li>The brain stem doesn't do the glamorous work; it simply keeps the body pumping, breathing, and controls most of the basic functions of survival. These functions include regular heart rate, blood pressure, temperature regulation, and respiration. (Teicher, 2002). </li></ul>
  7. 7. Brain Stem <ul><li>This section of the brain also controls the production and release of some neurotransmitters, and abnormalities which are associated with psychiatric disorders such as depression and psychosis </li></ul><ul><li>The memory stored in the brainstem is &quot;state memory&quot;. The brain remembers the optimal temperature range, the needed heart rate and rate of respiration to meet the needs of the organism </li></ul>
  8. 8. When the Brain Stem is Dysregulated <ul><li>Breathing rate increases </li></ul><ul><li>Breath volume decreases </li></ul><ul><li>Galvanic skin conductance increases </li></ul><ul><li>Heart rate increases </li></ul><ul><li>Pupil constriction </li></ul><ul><li>Increased adrenocortical hormone release in blood </li></ul><ul><li>Suppression of immune system </li></ul><ul><li>Changes in blood flow. </li></ul>
  9. 9. What would you see in children when chronically dysregulated? <ul><li>More focus on survival without clearly defined reasons to be aroused. (Edgy and on-guard) </li></ul><ul><li>Over-reactive to mild stressors (Constantly halfway to the jump-point) </li></ul><ul><li>Emotional volatility (Emotional storms of complex emotions) </li></ul><ul><li>Poor ability to learn from experience (just don’t seem to get it, no matter how many times told or shown) </li></ul>
  11. 11. DIENCEPHALON <ul><li>Motor regulation and the body's ability to negotiate its environment. </li></ul><ul><li>The diencephalon also regulates the critical functions of arousal , appetite and the regulation of sleep patterns. In some respects this region is the Energy Czar </li></ul>
  12. 12. DIENCEPHALON <ul><li>The memory stored in the diencephalon also includes motor functioning (muscle memory). </li></ul><ul><li>Physiological arousal like hunger, thirst etc. </li></ul>
  13. 13. DIENCEPHALON <ul><li>Aspects of dysregulation </li></ul><ul><ul><li>This Dysregulation effects serotonergic, opioid, dopaminergic, glutamatergic, thyroid and gabergic function. There are detrimental effects of glucocorticoid (GC) hypersecretion which occurs chronic activation </li></ul></ul><ul><ul><li>Obesity, Depression and Anxiety Disorders </li></ul></ul>
  14. 14. What would you see in children when chronically dysregulated? <ul><li>Constantly consuming food even when not hungry, particularly high calorie, fatty foods (mammal scarcity diet) </li></ul><ul><li>Lowered energy levels, fewer movements, less physical activity (preserving calories) </li></ul><ul><li>Increased depression </li></ul><ul><li>Restrict release of Endogenous opioids (feel good hormones) “endorphins” </li></ul>
  15. 15. Limbic System
  16. 16. Limbic System . . . (continued) <ul><li>Limbic System is the amygdala ( vital to emotional regulation ), hippocampus ( vital to forming and retrieving verbal and emotional memories </li></ul><ul><li>Often referred to as the emotion center of the body. Emotions are a very complex combination of perception, experience and memory , and body chemistry . It is the function of the limbic system to regulated these components. </li></ul>
  17. 17. Limbic System . . . (continued ) <ul><li>There are other very complex aspects of the body controlled by the limbic system that involve survival. </li></ul><ul><li>Reproduction and sexual behavior. </li></ul><ul><li>Attachment. </li></ul><ul><li>Memory stored in the limbic area is primarily affective experience. </li></ul>
  18. 18. Limbic System . . . (continued ) <ul><li>Specifically, the hippocampus is involved in verbal and emotional memory. </li></ul><ul><li>The hippocampus is very vulnerable to traumatic stress due to how slowly it develops and the density of its cortisol receptors (McEwen, 2000). </li></ul><ul><li>Some emotional memory is more available than others depending in part on the type of early experience. </li></ul>
  19. 19. Limbic System . . . (continued) <ul><li>The limbic system regulates arousal, emotions and behavior </li></ul><ul><li>This limbic system has been called the CEO of the social-emotional brain </li></ul>
  20. 20. Limbic System . . . (continued) <ul><li>It is common for traumatized individuals to have arrested emotional maturity around the age of abuse. </li></ul><ul><li>Some adults abused as children regress to childhood emotional responses when facing severe stress. </li></ul><ul><li>When trauma affects the arousal and emotional response of the body to stress, the impact on the individual can be pervasive. </li></ul>
  21. 21. Limbic System . . . (continued) <ul><li>Neurotransmitter depletion is diminished motivation, clinical depression, and a decline in optimal functioning. </li></ul><ul><li>Depletion of some neurotransmitters can result in over-dependence on other people, feelings of “I can’t make it without you,” (dependency) or in the opposite, an unrealistically independent (counter-dependent) stance of “I don’t need anyone; I can make it on my own” </li></ul>
  22. 22. What would you see in children when chronically dysregulated? <ul><li>Agitation and irritability </li></ul><ul><li>Sadness, grief, depression </li></ul><ul><li>Feeling hopeless (nothing they do will make things better) </li></ul><ul><li>Feeling numb (poor or little recognition of emotions) </li></ul><ul><li>Suspicious/untrusting (constant testing of every relationship) </li></ul>
  23. 23. What would you see in children when chronically dysregulated? <ul><li>Emotional outbursts (screaming, yelling, crying, etc) </li></ul><ul><li>Self-soothing or distracting behaviors </li></ul><ul><li>Poor communications (not effective and responding to feedback well, or making behavioral changes based on feedback) </li></ul><ul><li>Social withdrawal </li></ul>
  24. 24. What would you see in children when chronically dysregulated? <ul><li>Social isolative behaviors (doing things to create distance) </li></ul><ul><li>Poor Attachment (repeated failures to effectively engage in a relationship, or maintain relationships) </li></ul><ul><li>Pre-occupation with objects or environmental elements </li></ul><ul><li>Pre-occupation with stressors </li></ul>
  25. 25. What would you see in children when chronically dysregulated? <ul><li>Difficulty concentrating, focusing or attending </li></ul><ul><li>Appears inattentive or distracted </li></ul><ul><li>Difficulty making decisions </li></ul><ul><li>Difficulty following through on decisions to accomplish goals </li></ul><ul><li>Engages in pointless lies, deceptions or partial truths to avoid </li></ul>
  26. 26. What would you see in children when chronically dysregulated? <ul><li>Nightmares </li></ul><ul><li>Anxious behaviors </li></ul><ul><li>Worry about pleasing others </li></ul><ul><li>Physical complaints and mystery pain </li></ul><ul><li>Suppression of emotion </li></ul><ul><li>Tremors, pseudo-seizures </li></ul><ul><li>Acting much younger (emotionally) than age </li></ul>
  27. 27. What would you see in children when chronically dysregulated? <ul><li>Bed wetting </li></ul><ul><li>Magical thinking </li></ul><ul><li>Aggression and violent acts </li></ul>
  28. 28. Growing pains <ul><li>Basic Needs </li></ul><ul><ul><li>We are born with emotional needs for love, safety, acceptance, freedom, attention, validation of our feelings and a desire to physically be touched. </li></ul></ul><ul><ul><li>The origin of our identity is “LOVE” </li></ul></ul>
  29. 29. Growing pains <ul><li>Basic Needs </li></ul><ul><ul><li>These needs are felt and remembered at a cellular level (neurobiology), though we may not be intellectually aware of them. </li></ul></ul><ul><ul><li>They were experienced in a survival context in which the child was entirely dependent on others. </li></ul></ul>
  30. 30. Growing pains <ul><li>Basic Needs </li></ul><ul><ul><li>When these needs are left unmet or met in unpredictable ways they create compelling injunctions about the self, others and the world at large. </li></ul></ul>
  31. 31. Growing pains <ul><li>Basic Needs </li></ul><ul><ul><li>The problem! Early primal needs can be fulfilled only in childhood, since a significant element is the level of dependency. </li></ul></ul><ul><ul><li>In adulthood these needs can be fulfilled only partially, since we are past the developmental stage of dependence and many of our behaviors are not linked to survival any longer. </li></ul></ul>
  32. 32. <ul><li>Explains the biological components of behavior </li></ul><ul><li>Reduces belief in the intentionality of negative behaviors </li></ul><ul><li>Understanding that one must use how the brain operates to deliver effective interventions to traumatized children. </li></ul>Why is important to know the neurobiology?
  33. 33. A working definition that researchers are using to describe and define childhood trauma disorders. The simple composite of these is that “anything that interrupts or interferes with normal social, emotional, spiritual, psychological, cognitive, language or physical developmental processes can be considered traumatic”
  34. 34. Collaboration between Kaiser Permanente’s Department of Preventive Medicine in San Diego and the Center for Disease Control and Prevention (CDC) <ul><li>The Adverse Childhood Experiences Study </li></ul><ul><li>(ACE) </li></ul>
  35. 35. <ul><li>Psychological abuse by parents or caregivers (Psychological abuse occurs when one’s feelings, thoughts, preferences, desires, needs, appearance or friendships are trivialized or made to appear inconsequential relative to the parent or caregiver’s). </li></ul>
  36. 36. <ul><li>Physical abuse by parent or caregiver </li></ul><ul><li>Sexual abuse or exploitation </li></ul><ul><li>Physical neglect or abandonment </li></ul><ul><li>Emotional neglect (deprivation of empathy, nurturance, protection, and direction) </li></ul><ul><li>Were Substances abused in the home (with or without addiction) </li></ul>
  37. 37. <ul><li>Was there mental illness ( even mild) </li></ul><ul><li>Separation and divorce </li></ul><ul><li>Domestic violence (includes family screaming, yelling, the use of intimidation, threats of harm which may NOT include physical contact. </li></ul><ul><li>Parent or caregiver absent, or incarcerated </li></ul>
  38. 38. ACE Score = Trauma “Dose” Number of individual types of adverse childhood experiences were summed… ACE score Prevalence 0 32% 1 26% 2 16% 3 10% 4 or more 16% = 90%
  39. 39. Emotional Problems
  40. 40. Childhood Experiences Underlie Chronic Depression
  41. 41. Childhood Experiences Underlie Suicide 1 2 0 3 4+
  42. 42. ACE Score and Impaired Memory of Childhood ACE Score ACE Score 1 2 3 4 5
  43. 43. Health Risk Behaviors
  44. 44. Adverse Childhood Experiences and Current Smoking %
  45. 45. Childhood Experiences and Adult Alcoholism 0 1 2 3 4+
  46. 46. ACE Score and Intravenous Drug Use N = 8,022 p<0.001
  47. 47. <ul><li>ACE study data Suggests the basic cause of addiction is predominantly experience-dependent during childhood and not substance-dependent </li></ul><ul><li>Significant implications for medical practice and treatment programs </li></ul>
  48. 48. Serious Social Problems Poor Quality Relationships Unstable friendships Unstable employment Criminal involvement Poor educational experiences or successes
  49. 49. Adverse Childhood Experiences and Likelihood of > 50 Sexual Partners
  50. 50. ACE Score and Unintended Pregnancy or Elective Abortion
  51. 51. ACE Score and Indicators of Impaired Worker Performance
  52. 52. Adult Disease and Disability
  53. 54. Poor Life Expectancy
  54. 56. Environmental Factors <ul><li>There are five general environmental factors that contribute to the traumagneic family environments </li></ul>
  55. 57. #1 DISCONNECTION & REJECTION <ul><li>  ABANDONMENT /  INSTABILITY </li></ul><ul><li>MISTRUST / ABUSE </li></ul><ul><li>EMOTIONAL DEPRIVATION </li></ul><ul><ul><li>Deprivation of Nurturance :  Absence of attention, affection, warmth, or companionship. </li></ul></ul><ul><ul><li>Deprivation of Empathy :  Absence of understanding, listening, self-disclosure, or mutual sharing of feelings from   others. </li></ul></ul><ul><ul><li>Deprivation of Protection :  Absence of strength, direction, or guidance from others. </li></ul></ul><ul><li>DEFECTIVENESS / SHAME  </li></ul><ul><li>SOCIAL ISOLATION / ALIENATION </li></ul>
  56. 58. Behaviors in children for Environment One <ul><li>Constant monitoring of others trying to discern what they are feeling. </li></ul><ul><li>Upset when others are in distress, wants intense emotions to be quickly calmed or avoided </li></ul><ul><li>Must be liked and approved of by others </li></ul><ul><li>Take on responsibilities for other’s welfare and emotional well-being </li></ul><ul><li>Constantly be on alert for others feeling distressed, uncomfortable or emotional </li></ul><ul><li>Feel fearful when there are any signs of conflict, aggression or emotional intensity present </li></ul>
  57. 59. Behaviors in children for Environment One <ul><li>Feel that they must meet parental expectations at all times, even as a adults with their own needs and self-expectations. </li></ul><ul><li>Major efforts to anticipate and predict parental needs and desires, and works diligently to fulfill them. </li></ul><ul><li>Feel incredibly guilty for wanting their own needs met </li></ul><ul><li>Feel that they need to sacrifice their own needs for the welfare of their parents </li></ul><ul><li>Controlling of others </li></ul><ul><li>Critical </li></ul><ul><li>Never satisfied </li></ul><ul><li>Takes offense easily </li></ul>
  58. 60. #2 IMPAIRED AUTONOMY & PERFORMANCE <ul><li>Dependence / incompetence </li></ul><ul><li>Vulnerability to harm or illness  </li></ul><ul><li>Enmeshment  /  undeveloped self   </li></ul><ul><li>FAILURE - The belief that one has failed,  will inevitably fail, or is fundamentally inadequate . </li></ul>
  59. 61. Behaviors in children for Environment Two <ul><li>Exist as extensions of the parent </li></ul><ul><li>Must attend to and at most times admire the parent </li></ul><ul><li>Never show independence or autonomy </li></ul><ul><li>Clingy </li></ul><ul><li>Overly nurturing </li></ul><ul><li>Make a big deal out of little inconveniences </li></ul><ul><li>Complaining, nagging and whining </li></ul><ul><li>Easily hurt and emotionally reactive </li></ul>
  60. 62. Behaviors in children for Environment Two <ul><li>Wants to know every thought and feeling </li></ul><ul><li>Holds grudges </li></ul><ul><li>Engages in self-soothing and self-comforting behaviors </li></ul><ul><li>Can seem sympathetic, but rarely truly empathic </li></ul>
  61. 63. #3 IMPAIRED LIMITS <ul><li>Deficiency in internal limits, responsibility to others, or long-term goal-orientation. Leads to difficulty respecting the rights of others, cooperating with others, making commitments, or setting and meeting realistic personal goals. </li></ul><ul><li>Typical family is characterized by permissiveness, overindulgence, lack of direction, or a sense of superiority -- rather than appropriate confrontation, discipline,  and  limits in relation to taking responsibility, cooperating in a reciprocal manner, and setting goals. </li></ul>
  62. 64. Behaviors in children for Environment Three <ul><li>Flamboyant </li></ul><ul><li>Dramatic </li></ul><ul><li>Restless, moves from person to person, project to project, thought to thought </li></ul><ul><li>Manic at times </li></ul><ul><li>Resents those that perform better and more successfully, and will frequently bully or make fun of them </li></ul><ul><li>Exaggerates accomplishments and ailments </li></ul><ul><li>Over-estimates their own abilities, and talents </li></ul><ul><li>Ignores authority </li></ul>
  63. 65. Behaviors in children for Environment Three <ul><li>Intrusive </li></ul><ul><li>Does not respect personal or societal boundaries </li></ul><ul><li>Assumes that they will be the center of attention </li></ul><ul><li>Takes advantage of others </li></ul><ul><li>Is manipulative </li></ul>
  64. 66. #4 OTHER-DIRECTEDNESS <ul><li>An excessive focus on the desires, feelings, and responses of others, at the expense of the child’s own needs -- in order to gain love and approval, maintain one's sense of connection, or avoid retaliation.   </li></ul><ul><li>Usually involves suppression and lack of awareness regarding one's own emotions and natural inclinations. </li></ul><ul><li>Typical family origin is based on conditional acceptance: children must suppress important aspects of themselves in order to gain love, attention, and approval.   </li></ul>
  65. 67. Behaviors in children for Environment Four <ul><li>Overly nurturing </li></ul><ul><li>Overly compliant </li></ul><ul><li>Feeling flawed or broken </li></ul><ul><li>Unable to protect themselves or be assertive </li></ul><ul><li>Feel powerless to keep others from hurting, or taking advantage </li></ul><ul><li>I must take care of others or I will never be loved </li></ul><ul><li>I am not as good (able, intelligent, and so on) as others are </li></ul><ul><li>Get anxious when alone </li></ul>
  66. 68. #5 OVERVIGILANCE  & INHIBITION <ul><li>An excessive emphasis on suppressing the child's spontaneous feelings, impulses, and choices OR on meeting rigid, internalized rules and expectations about performance and ethical behavior -- often at the expense of happiness, self-expression, relaxation, close relationships, or health. </li></ul><ul><li>Typical family origin is grim, demanding, and punitive: performance oriented, duty and perfectionism are highly prized values, following rules, hiding emotions, and avoiding mistakes dominate over warm relationships, pleasure, joy, and relaxation.   </li></ul>
  67. 69. Behaviors in children for Environment Five <ul><li>Critical and criticizing </li></ul><ul><li>Never satisfied </li></ul><ul><li>Picky </li></ul><ul><li>Demands perfection </li></ul><ul><li>Uses instrumental anger </li></ul><ul><li>Makes demeaning or devaluing comments to and about others </li></ul><ul><li>Blames others </li></ul><ul><li>Hypersensitive to perceived slights and criticisms </li></ul><ul><li>Manipulates </li></ul><ul><li>Coercive </li></ul>
  68. 70. Behaviors in children for Environment Five <ul><li>Dismisses others as inferior </li></ul><ul><li>Lies and cheats </li></ul><ul><li>Must win at all costs </li></ul><ul><li>Arrogance </li></ul><ul><li>Superiority </li></ul>
  69. 71. The Formation Of A Personally Meaningful Belief Systems Called Injunctions
  70. 74. So now that you know this stuff, what can you do with it?
  71. 75. Advocacy! <ul><li>Many report that dealing with Helpers is a challenge and that these Helpers view family as something to get over. </li></ul><ul><li>Systems like schools and CPS tend to have a very narrow view that “blames” individuals or families as the problem. </li></ul><ul><li>Helpers are sometimes naïve about the reality of the system. </li></ul><ul><li>Address child behavior problems through behavioral methods without exploring how these behaviors may be connected to past deprivation, trauma or adoption; </li></ul><ul><li>Suggest that the parents “just got a bad one” and urge families to return the child to the state. </li></ul>
  72. 76. Family Expectations: <ul><li>What was the family’s initial experience of adoption? </li></ul><ul><li>What were the parent’s dreams? </li></ul><ul><li>When did the dreams begin to disintegrate? </li></ul><ul><li>How, specifically, did the reality differ from the dream? </li></ul><ul><li>What were the consequences of adopting this child? </li></ul>
  73. 77. Core Issues of Adoption <ul><li>The Effects of Loss </li></ul><ul><li>Central to adoption process </li></ul><ul><li>Adoption is not possible without loss </li></ul><ul><li>Adopted person has loss – genetic identity, loss of relationships with emotionally significant objects </li></ul><ul><li>Adopted family has loss – infertility; loss of continuity with biological lineage; </li></ul><ul><li>Birth parents have loss – surrender of child; loss of information about the child </li></ul>
  74. 78. Core Issues of Adoption <ul><li>The Effects of Loss </li></ul><ul><li>Loss is healed through grief </li></ul><ul><li>Grief is revisited over time </li></ul><ul><li>Developmental tasks trigger loss – adolescence, marriage, college, childbirth </li></ul><ul><li>Some behavior in adopted persons viewed as pathological may actually be maladaptive grieving – i.e., concepts of rejection </li></ul>
  75. 79. Core Issues of Adoption <ul><li>Issues in Attachment </li></ul><ul><li>Cycle of need and response </li></ul><ul><li>Infant basic needs/keep caretaker close </li></ul><ul><li>FAS – attachment challenges </li></ul><ul><li>Trust, intimacy, caretaker dependability </li></ul><ul><li>Dependency needs may be greater than parent’s ability – black hole – sieve syndrome </li></ul><ul><li>Attachment is on a continuum </li></ul>
  76. 80. Core Issues of Adoption <ul><li>Issues in Attachment </li></ul><ul><li>Attachment is a two way street </li></ul><ul><li>Ability to attach complicated by physical or temperamental difference </li></ul><ul><li>Adoptive parents with attachment issues may believe that such a mismatch would never have occurred with a child born to them. </li></ul>
  77. 81. Core Issues of Adoption <ul><li>Identity Issues </li></ul><ul><li>Both adopted parents and adopted persons must incorporate “being adopted” into their sense of self. </li></ul><ul><li>Who am I? </li></ul><ul><li>Where do I come from? </li></ul><ul><li>How does this impact on my life? </li></ul><ul><li>Openness is key </li></ul><ul><li>Be comfortable with ambiguity </li></ul>
  78. 82. Core Issues of Adoption <ul><li>Mastery and Control Issues </li></ul><ul><li>Basic need for competence and personal power in one’s life </li></ul><ul><li>Control over one’s life; control over creating family; control over one’s child by birth </li></ul><ul><li>Control battles are common in adoptive families as each party seeks to gain control over their lives and situations </li></ul>
  79. 83. We Never Thought it Would be Like This! Problems Identified by Families <ul><li>Behavior problems of child 89% </li></ul><ul><li>Emotional problems of child 72% </li></ul><ul><li>Child-Parent relationship 61% </li></ul><ul><li>Child’s relationship w/ peers 48% </li></ul><ul><li>Financial problems 46% </li></ul><ul><li>Child care problems 37% </li></ul><ul><li>Emotional problems – parent 26% </li></ul><ul><li>Job problems 25% </li></ul><ul><li>Marital problems 24% </li></ul>
  80. 84. We Never Thought it Would be Like This! Problems Identified by Families <ul><li>Common Themes </li></ul><ul><li>Limited Emotional Range – anger/sorrow </li></ul><ul><li>Marital Tensions </li></ul><ul><li>Sibling Issues </li></ul><ul><li>Isolation </li></ul><ul><li>Exhaustion and Hopelessness </li></ul><ul><li>Running on Empty </li></ul>
  81. 85. The Adoption Triad <ul><li>Adoptive Family </li></ul>Adoptee Birth Family
  83. 87. COMMON PRESENTING ISSUES <ul><li>Lack of understanding/anger </li></ul><ul><li>Parenting struggles </li></ul><ul><li>Lack of “goodness of fit” </li></ul><ul><li>Low self esteem & identity issues </li></ul><ul><li>Feelings of loss of control </li></ul><ul><li>Grief due to loss </li></ul><ul><li>Inability to develop & maintain intimate relationships </li></ul>
  84. 88. SELF ESTEEM <ul><li>Cornerstone of mental health </li></ul><ul><li>Professionals must recognize constellation members’ vulnerabilities </li></ul><ul><li>Parents must be empowered and taught how to build their child’s self esteem </li></ul>
  85. 89. FOSTERING SELF ESTEEM <ul><li>Provide opportunities to try new things </li></ul><ul><li>Allow chances to feel “in charge” </li></ul><ul><li>Balance expectation & ability </li></ul><ul><li>Allow for mistakes </li></ul><ul><li>Validate feeling & thoughts </li></ul><ul><li>Model appropriate behavior & attachment </li></ul><ul><li>Use filial therapy </li></ul>
  86. 90. <ul><li>Questions? </li></ul><ul><li>Questions? </li></ul><ul><li>Questions? </li></ul><ul><li>Questions? </li></ul><ul><li>Questions? </li></ul><ul><li>Questions? </li></ul>