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

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Dr. Rebecca Wild, Royal Australian and New Zealand College of Psychiatrists Queensland Branch, Advanced Cert. Child and Adolescent Psychiatry, Child and Adolescent Psychiatrist delivered the "Impact ...

Dr. Rebecca Wild, Royal Australian and New Zealand College of Psychiatrists Queensland Branch, Advanced Cert. Child and Adolescent Psychiatry, Child and Adolescent Psychiatrist delivered the "Impact of cumulative harm and the options for supporting recovery" presentation at the Child Protection Forum 2013.

She spoke about cumulative harm, working together to help children heal, neurobiological impact of trauma on the developing brain, and treatment for children with advanced behavioural or medical challenges.

Find out more at http://www.informa.com.au/childprotectionforum2013

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

  • 1. CHILD PROTECTION CONFERENCE SYDNEY 2013 Dr. Rebecca Wild Child Psychiatrist Working together to help children heal: what does it take?….
  • 2. 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.
  • 3. 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.
  • 4. 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
  • 5. Complex Trauma  Type two  Also consider relational, intentional, role of primary attachment figure.  Pre-verbal
  • 6. 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)
  • 7. Diagnosis  Meeting criteria is necessary but not sufficient  Diagnosis incorporates context  Checklists and screening instruments are tools only.
  • 8. Developmental trajectory 0 2 5 10 15 20 25 normative reparative compound trauma no reparation unconsolidated reparative care
  • 9. 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
  • 10. Principles of Treatment What helps them heal?  Prevent or reduce further cumulative harm.  Thorough assessment and individualised therapeutic intervention
  • 11. 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.
  • 12. 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
  • 13. 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
  • 14. 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
  • 15. 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
  • 16. 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
  • 17. 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
  • 18. 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
  • 19. 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?
  • 20. 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.
  • 21. 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
  • 22. 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
  • 23.  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
  • 24. END
  • 25. 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
  • 26. 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
  • 27. 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?
  • 28. 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
  • 29.  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
  • 30. 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
  • 31. 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
  • 32. 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
  • 33. 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
  • 34. 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
  • 35. 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
  • 36. 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
  • 37. 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
  • 38. 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
  • 39. 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
  • 40. 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
  • 41. 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
  • 42. 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
  • 43. 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
  • 44. 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
  • 45. 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
  • 46. 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
  • 47. 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
  • 48. 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
  • 49. 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
  • 50. 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
  • 51. 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
  • 52. 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
  • 53. 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
  • 54. 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
  • 55. 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
  • 56. 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
  • 57. 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