3/15/17
‘Siblings who are a ‘TAD’ troubled’
© Lynne Ryan 2011
.
(Trauma, Attachment & Dissociation)
TheTroubledTriangle:
TRAUMA
ATTACHMENTDISSOCIATION
Trauma almostalwaysresultsindissociation inchildren,
particularlyyoungchildrenandtraumainterruptsthe
attachmentprocess.
Suffolktraining17March2017
PresentedbyLynneRyan- SeniorTherapist,IntegrateFamilies
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
1
TAD– workshop17March2017
• Aimsoftoday’sworkshop:
• ToexploretheinterplayofTrauma,Attachment
andDissociationonthechildandthesibling
groupusingtheoryandcasestudies.
• Topresenta‘BrainyGuide’,totraumapsychoeducationi.e.informationaboutthebrain&
body'sresponsetotrauma
• Toexplorepracticalinformationandstrategiesto
assisttheTADtroubledsiblinggroup
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
2
1
3/15/17
CurrentGuidancereSiblingsinCare
• Definitionofsiblings:- nolegaldefinition,butadefinitionisas
follows:Childrenwhoshareatleastoneparentand/orliveor
havelivedforasignificantperiodwithotherchildreninafamily
group– canincludestep-siblings,halfsiblingsorunrelatedchildren
whohavebeenbroughtuptogether.
• UKguidance:ChildrenAct1989S23(7(b)– emphasisesneedto
placesiblingstogether,‘sofarasisreasonablypracticaland
consistentwithhiswelfare’.
• Socialworkershavetomakeclear,evidencebaseddecisions,on
whethertoplacesiblingstogetherorseparately.Assessmentsneed
toconsiderthebestinterestsofindividualchildren,inadditionto
•
withinthesiblinggroup
•
•
Thestartingpointisalwaysthatsiblingsshouldbeplaced
together
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
3
AssessingSiblingsforplacement
• Importanceofinvolvingthechild/thechild’svoice(keyto
thesignsofsafety(SoS)approach)
• Assessmentmethods:observation;questionnaires–
individualrechildorsiblingspecifice.g.sibling
relationshipschecklist;interview– withchild,family,
siblingscarersetc.;projectivetechniques- e.g.thoseused
withinSoS (signsofsafetymethod)– threehouses,witches
andwizardetc.
• Decisionsreplacingtogetherorapartinfluencedby:law;
agencypolicy;child’swishes&feelings;family/sibling
wishesandfeelings;personalbeliefsofprofessionals–
socialworkers;fostercarers;panelmembers;judgesetc.
child’sageandstageofdevelopment;culturalidentity;
healthneeds;careplanetc.……………………..
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
4
2
3/15/17
TheComplexityoftheSiblingGroup
• Individualneedsofchildvs
Siblinggroup
• Natureoftherelationship– full
/halfsibling
• Competingneeds/wishes
• Contact– purposequalityetc.
• Nomagicformula– but
havetoconsiderthechildin
context:cultural/ethnic;presentation1:1;
withsiblinggroup;withfamilygroup;with
parents;withprofessionals…
&assessaccordinglyand
HOLISTICALLY
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
5
Siblings:Together
orApart?
•
•
•
•
•
Pros – theplacementofsiblingstogetherhasbeenlinkedtobenefitssuchas:
continuity;Security;identity;betteroutcomes(Rushton2001)andgreater
placementstability(Hegar 2005)
Cons– contraindicatorstoplacingsiblingstogether– Furman&Buhrmester
1985:dependupon4keyfactors:degreeofwarmth;degreeofconflict;
degreeofrivalryanddegreetowhichonesiblingnurturesordominatesthe
other.Gerrilyn Smithaddedthefollowingfactorswhichmayindicateseparate
placements:rivalry;exploitationbasedongender;chronicscapegoatingof
onechild;highlysexualisedbehaviour;actingastriggertootherstrauma.
FamilyFutures(2007)maketheassertionthatsinceCA1989,thatthecare
populationsufferedgreaterdevelopmentalharmduetoraisedthresholdsand
thereforetheprosmaybeoverlyoptimisticfortodayscarepopulation.They
quoteHadleyCentrestudy(2006),whichstatesthatchildrenplacedfor
adoption,suffersomedegreeofdevelopmentaltraumawhichaffectsthe
siblingrelationshipandthetypeofparentingrequired
Lord&Borthwick 2009,inanupdateoftheir2001research,arguefora
‘comprehensiveassessmentofthechildandtheirsiblingrelationshipasa
precursortomakingdecisionsaboutsiblingplacements’.
Iwouldaddthatthereisaneedtounderstandtheimpactoftraumaon
individualchildren,beforeexploringtheimpactuponthesiblinggroup–
using
Copyright©2017LynneRyan- Integrate
a‘BRAINYRESPONSE’ Families&BICTDUnauthorisedcopyingor
6
distributionstrictlyprohibited.
3
3/15/17
WhatisTrauma?
(TheTinTAD)
TraumameansINJURY
TheDSMIV*Definestraumaas:
• Aneventwhichis,orrealisticallyperceivedtobe,
threateningtothelifeorpersonalintegrityofselfand
othersand
• Theresponsetotheeventisoneoffear,helplessnessor
horror
*TheDiagnosticandstatisticalmanualofMentalDisorders(fourthedition)(DSMIV),publishedbythe
AmericanPsychiatricAssociation,isadiagnosticreferenceofmentalhealthprofessionalsintheUnited
States.Itincludesdiagnosticcriteriaforthemostcommonmentaldisorders,includingdescription,
diagnosis,treatmentandresearchfindings.
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
7
Trauma
TheTinTAD
• Theautomaticresponsetotrauma,involvingthe
productionoftoxicamountsofstresshormones
whichaffect:
– allmajorbodysystems
– brainfunction*
– socialfunctioning
• Abio-psycho-socialinjury
(BAAFSaferCaring:trainingprogramme
KateCairns2007)
CHILDABUSE– PHYSICAL,SEXUAL&/OR
EMOTIONAL,PRODUCESTRAUMAINTHECHILD
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
8
4
3/15/17
Traumachangesbeliefs
• Throughrelationshipswithimportantattachmentfigures,
childrenlearntotrustothers,regulatetheiremotions,and
interactwiththeworld;theydevelopasenseoftheworld
assafeorunsafe,andcometounderstandtheirownvalue
asindividuals.
• Whenthoserelationshipsareunstableorunpredictable,
childrenlearnthattheycannotrelyonotherstohelpthem.
Whenprimarycaregiversexploitandabuseachild,the
childlearnsthatheorsheisbadandtheworldisaterrible
place. ThislinksintotheAintheTADmodelAttachment
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
9
WhatIsAttachment?
(TheAinTAD)
• Attachmentisthecapacitytoformandmaintain
healthyemotionalrelationships.Anattachmentbond
hasuniqueproperties.Thecapacitytocreatethese
specialrelationshipsbeginsinearlychildhood.
UniqueFeaturesofanAttachmentBond:
• Enduringformofabondwitha"special"person
• Involvessoothing,comfort,andpleasure
• Lossorthreatoflossofthespecialpersonevokes
intensedistress
• Thereissecurityandsafetyincontextofthis
relationship
Dr.BruceD.Perry
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
10
5
3/15/17
Creationofasecurebase:
1st YearCycle:
From Attachment disorder web site - www.attachmentdisorder.net
If a child is securely attached, when they are upset, they know that they can approach an
adult directly and have their needs met.
The need – e.g. hunger, pain etc. leads to crying / rage which is relieved when the need is
met by the caregiver through e.g. food eye contact, touch etc. which in turn leads to trust
and the belief that the world is safe and adults are ok and the child is ok.
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
11
DisturbedAttachmentcycle
From Attachment disorder web site - www.attachmentdisorder.net)
If the baby’s needs are not met in the first year, this results in a disturbed
attachment cycle and the child feels that the world is not safe, they are
not ok and adults are untrustworthy.
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
12
6
3/15/17
Thechildwithattachmentdifficultiesmaypresent
withthefollowing:
•destructivetoselfandothersandbelongings
•lieaboutridiculousthings
•steal
•slowlearners– learningimpeded
•lackofcauseandeffect
•lackofconscience
•poorpeerrelationships
•persistentnonsensequestionsandchatter
•inappropriatelydemanding
•presumptiveentitlementissues
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
13
AttachmentStyles
Secure: Usescaregiveras asecurebaseforexploration. Showsappropriate distress
whenthecaregiver leavesiscomfortedonreturn, returningtoexploration.May be
comfortedbythestrangerbutshowsclearpreference forthecaregiver.
Ambivalent: Doesnotusethecaregiverasasecurebase, forexploration,protesting
beforethe caregiverleaves.Upsetaboutthe caregiverleavingandslowtowarmon
return. Expressedconcernaboutthecaregiverslocation, seekingcontactbutresisting
angrily whenitisachieved.Noteasilycalmedbystranger. Inthisrelationship,the
childalwaysfeels anxiousbecausethecaregiver'savailability isneverconsistent.
Avoidant:Littleemotionalsharinginplay. fewsignsofemotionwhen thecaregiver
leavesorreturns, Showinglowaffectwhenofferedaffection. Treatsstrangers
similarlytocaregivers. Thechildmayexpresslackofattachment andlowselfesteem
byactingout.
Disorganized:Lackofattachmentcan beexpressedbydisorganized emotional
behavioursuchas approachingthecaregiver butwiththebackturned.
*AinsworthMD,Blehar M,WatersE,WallS(1978). PatternsofAttachment:A
PsychologicalStudyoftheStrangeSituation. Hillsdale
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
14
7
3/15/17
Whattheinsecurelyattachedchild
needs:
SAFETY&SECURITY
Toreducetheiranxiety
Helptodeveloprelationships
Helptodevelopself-awareness(including
beingintouchwiththeirbodiessenses)
• Helptobecalmandtolearnselfregulation
•
•
•
•
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
15
WhatisDISSOCIATION?
(TheDinTAD)
•
•
Definition: “Adisruptionintheusuallyintegratedfunctionsof
consciousness,memory,identityorperceptionsoftheenvironment”
DSM,AmericanPsychiatricassociation1994.
•
Infantsandchildrenwhosuffertraumaticevents– includingabuseand
neglect,areparticularlylikelytousedissociation(i.e.psychologically
‘movingaway’fromdanger)asasurvivalstrategy.(Wieland2011).
•
Parentsandteachersoftenreportexcessive‘spacingout’,‘daydreaming’
andinconsistentperformance.Theyalsooftennoticedrapidchangesof
emotionalstatesandincessantlying,evenwhentherewasawitnesswho
hasobservedthemdoingsomethingwrong.
ESTDUK2011
•
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
16
8
3/15/17
Dissociation
•
“Whenachildfeelsveryafraidandhelplessandcannotphysicallyescape
fromthesituation,hecanfindawayto‘escape’byblockingoff
(dissociating)theterrifyingevent/sfromhismemory;byblockingoff
(dissociating)feelingsofpain,hurt,rage;andbyblockingoff(dissociating)
badthoughtsabouthimselfandthosehurtinghim.Hemaygointoa
trancestateor‘spaceout’(milddissociation).Hemaybecomeunawareof
hissurroundings(moderatedissociation).Hemayevenseparate
completelyfromhimselftototallyescapefromthefrighteningevent/s
(severedissociation).Thisisasurvivaltechniquethatcanbehelpfultothe
childatthetimeofthescaryevent.Itiswhenthisseparationcontinuesto
occurwithotherthreateningeventsorwithreminders– called‘triggers’
ofthetraumaticeventthatitisproblematic.Thisdissociationmaykeep
himfromdevelopingnormally,forminghealthyattachments,andmeeting
social,academic,andemotionalexpectations”.(ISSTDwebsiteaccessed
January2011).
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
17
BrainsNotbehaviour!!
• Withtraumatisedchildren,theaimisto
encouragehealthybraingrowth
• Wecan‘manage’behaviour,butthisultimately
doesnotchangethebraininanymeaningfulway
(Gettotherootratherthanjustpickingthe
leaves!– theygrowback!!!)
• Thechild'sbehaviouristheirwayto
communicatewhatishappeningintheirbrains
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
18
9
3/15/17
BrainDevelopment*
Thebraindevelopssequentially:
Brainstem: stateregulation
Beforebirth– eightmonths
Mid-brain: motorfunctioning
Birth– oneyear
Limbicbrain: emotionalfunctioning
Sixmonths– twoyears
Cortex: cognitivefunctioning
Oneyear– fouryears
(*Siegal’shandmodel)
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
19
UnderstandtheBrainUsingthePalmof
YourHand
(Handpuppet– anotherpsycho-educativetool)
Ifyouholdupyourhandinafistwithyourfourfingerscurled
overyourthumbandyourfingersfacingyou,thismakeswhat
Siegelcalls“asurprisinglyaccurategeneralmodelofthe
brain.”Yourwrististhebrainstem,whereyourbrainconnects
withyourspine.Yourthumbrepresentsthelimbicsystemasa
wholeand,specifically,theamygdala—thefightflightpartof
yourbrain.Theamygdalaisalsowhereyoustoreemotional
pain,fears,anddecisions(inaccurate)thatyouarenot“good
enough.”
Yourcurledfingersand,specifically,yourfingernails,
representtheprefrontalcortex—theonlypartofyourbrain
wherethinkingtakesplace.
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
20
10
3/15/17
TheTriuneBrain(mclean)
• Thereptilianbrain- thesensorimotorlevelisthemost
primitivepartandisresponsiblefortheautomatic
functionsinthebodysuchasbreathingandheartbeat
&inthispartofthebraininformationisprocessedona
sensorimotorlevel.
• Themammalianbrainwhereinformationisprocessed
onanemotionallevelisalsocalledthelimbicsystemof
theemotionalbrain.
• Thecognitivelevelistheneo-cortexthisiswherethe
abilityforlanguageabstractthinkingandreasoning
learningandplanningdeliberateactionsreside.
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
21
BrainDevelopment
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
22
11
3/15/17
The6R’s(BrucePerry)forTRAUMA
HEALING
• Traumahealing,saysPerry,requires6R’s;it
mustbe:
•Relational (safe)
•Relevant (developmentally-matchedtothe
individual)
•Repetitive (patterned)
•Rewarding (pleasurable)
•Rhythmic (resonantwithneuralpatterns)
•Respectful (ofthechild,family,andculture)
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
23
Repetition,Repetition,Repetition
• “Tochangeanyneuralnetworkinthebrain,weneedtoprovide
patterned,repetitiveinputtoreachpoorlyorganizedneuralnetworks
involvedinthestressresponse.Anyneuralnetworkthatisactivatedin
arepetitivewaywillchange,”
• development,themoreeffective…
• “Thefirststepintherapeuticsuccessisbrainstemregulation…Start
withthelowestundeveloped/abnormallyfunctioningsetofproblems
andmovesequentiallyupthebrainasimprovementsareseen…
• “Anexampleofarepetitiveinterventionispositive,nurturing
interactionswithtrustworthypeers,teachers,andcaregiver…using
patterned,repetitivesomatosensoryactivitiessuchasdance,music,
movement,yoga, drummingortherapeuticmassage… Thisistrue
especiallyforchildrenwhosepersistingfearstateissooverwhelming
thattheycannotimproveviaincreasedpositiverelationships,oreven
therapeuticrelationships,untiltheirbrainstemisregulatedbysafe,
predictable,repetitivesensoryinput.”
• Perry(2006).
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
24
12
3/15/17
Howtoputallofthisbrainystuff
intopractice
• Whatcanwedo??InasafeRELATIONSHIPwe:
• REPAIR – thechild’sunhealthyrelationships&
experiences
• REGULATE- thechild’semotions
• REWIRE– thebrain– encourage&REPEAT
healthybrainconnections
• Re-educate – thechildabouttheirbrains!
(Psycho-education– seenextslide)
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
25
InthecontextofthesiblingGroup?
• Supportiskey– healingonetraumatisedchildinvolvesintense
effort,resourcesandtime.Thisismultipliedwherethereare
severaltraumatisedchildrenlivinginonefamily.
• Eachchildrequirestheirindividualneedstobemet– eachchild
needsaprimarycarerwhocanrepairtheirattachmentrelationship
andpotentiallysupportthemthroughtherapytoprocesstrauma
andaddressdissociation,inadditiontodailytherapeuticparenting
activities.(Repetition,repetition,repetition…)
• Inadditiontoindividualinput,dependinguponthesibling
relationship,extrasupervision/separationmaybenecessaryinthe
home;awarenessandinterventionstopreventtraumare-enacment
inthesiblingrelationshipmaybeindicatedandindividualand/or
familytherapymayberequired.
• Leavittetal(1988),suggestedthefollowingmaybealsorequired:
suspendingproblematicsiblingrelationshipstocreateroomfor
bondingwithcaringadults,transferringattachmentbehavioursand
impulsestoareceptiveadult,resuminghealthyindividual
development,formingmoreadaptivesiblingconnections,and
Copyright©2017LynneRyan- Integrate
expressingsharedtraumaticcontent.
Families&BICTD- Unauthorisedcopyingor
26
distributionstrictlyprohibited.
13
3/15/17
Insummary
• TheRELATIONSHIPiskey– achildrequiresanadulttodevelopasecure
attachmentrelationshipwith.
“Everychildneedsatleastoneadultwhoisirrationallycrazy
abouthimorher”.
Urie Bronfenbrenner – psychologist.
•
AdultsmustremainREGULATEDinordertohelp
childrenREGULATE theirbrains
• Withearlycomplextrauma,interventionsneedtostartwithbrainstem–
sensorylevel– moveupthroughlimbic– attachmentandfinally– cortexwords,thinking,causeandeffect– ACTIONSbeforeWORDS
• Tomakeorstrengthenbrainpathways,wemust REPEAT,REPEAT,
REPEAT…..
• Alloftheaboveismultipliedinaccordancewiththesizeofthesibling
group
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
27
Andfinally…..
“Idon’tbelieveanaccidentofbirth
makespeoplesistersorbrothers.Itmakes
themsiblings,givesthemmutualityof
parenting.Sisterhoodandbrotherhoodis
aconditionpeoplehavetoworkat”.
MayaAngelou
Copyright©2017LynneRyan- Integrate
Families&BICTD- Unauthorisedcopyingor
distributionstrictlyprohibited.
28
14