By Kathleen Ann Bush, MA, LCPC







Clinical Services Manager of Foster Care Therapy
and Adoption Preservation at The Baby Fold
Masters in Human Development Counseling
Licensed Clinical Professional Counselor
21 years in working with kids and adults with
attachment issues and trauma
Supervisor of both foster care therapists and
adoption preservation therapists for 7 years
I have a passion for figuring what works and
what works most efficiently for our kids
I also have a passion for training therapists well
In this workshop you will learn how our
agency has incorporated the Trust
Based Relational Intervention (TBRI)
therapeutic parenting model developed
at Texas Christian University into the
Attachment, Regulation, & Competency
(ARC) therapy model developed by
Margaret E. Blaustein and Kristine M.
Kinniburgh.
For understanding client/family
issues,
 improving parents’ mindfulness,
 providing concrete positive parenting
techniques, and
 significantly improving the emotional
connection of adoptive parents to
their children.


Adoption Preservation which incorporates EB/EI
practice and techniques.
◦ Design elements
In-home intensive family and individual therapy
In-home intensive parent modeling/training
Support groups for both parents and children
Psycho-education classes (Trust-Based Relational Intervention)
Case management (referrals, support in obtaining resources)
School support (attend IEP’s, behavior assessment, TBRI
training)
 Respite funds
 Emergency funds
 Camp Take-A-Break: a sleep away weekend camp for kids to
give parents respite.














ARC Model
Theraplay
TF-CBT
EMDR
Integrative Attachment EMDR
Attachment Focused Family Therapy- Dan
Hughes
Parent Child Interaction Therapy
Trust Based Relational Intervention (TBRI)


Embracing evidence based and informed
practice adopted the ARC model about 5
years ago under the guidance our Clinical
Director Dr. Robert Lusk.
Participated in a research project with
Northwestern University, Illinois Department
of Children and Family Services (DCFS) and
the developers of ARC in collaboration with
10 child welfare agencies across the state of
Illinois.
Trauma
Integration
(Phase One)
Executive
Functions
Feelings
Identification
Caregiver
Affect
Management
Identity/
Sense of Self
Affect
Modulation
Attunement
(Phase Two)
Feelings
Expression
Consistent
Caregiver
Response
Routines &
Rituals
9


Among trauma treatments, the research
evidence is strongest for Trauma-Focused
Cognitive-Behavioral treatment (TF-CBT), and
treatment protocols that incorporate aspects
of TF-CBT
◦ The ARC model incorporates the TFCBT model very well
TF-CBT is not always enough for clients
with complex trauma
Am J Psychiatry 167:8, August 2010
10



Therapists across the state were doing well in
reducing child behaviors, anxiety and
symptoms of trauma.
Attachment didn’t seem to budge in the study
results as a whole, but in our case study we
did see huge improvements.
What was the difference?
◦ Our staff are trained in attachment work and focus
on the principals that TBRI teaches.
◦ ARC and TBRI work really well together.





The parent may have difficulty with their own
regulation.
The child may be rejecting his/her parent.
The parent may lack understanding of the
reasons behind the child’s behavior.
The child may have a developmental delay or
sensory issue that the parent isn’t aware of.
The child may present a danger to others in
the home.

Possible reason for lack of progress
◦ Bessel Van Der Kolk says 75% of us have trauma






Physical
Emotional
Single incident
Adoptive trauma
Loss
Etc..



The ACE Study is ongoing collaborative research
between the Centers for Disease Control and
Prevention in Atlanta, GA, and Kaiser Permanente
in San Diego, CA
The Co-principal Investigators of The Study are
Robert F. Anda, MD, MS, with the CDC; and
Vincent J. Felitti, MD, with Kaiser Permanente.
Over 17,000 Kaiser patients participating in
routine health screening volunteered to
participate in The Study. Data resulting from
their participation continues to be analyzed; it
reveals staggering proof of the health, social, and
economic risks that result from childhood
trauma.










Physical abuse
Sexual abuse
Emotional abuse
Physical neglect
Emotional neglect
Mother treated violently
Household substance abuse
Household mental illness
Parental separation or divorce
Incarcerated household member
https://en.wikipedia.org/wiki/Adverse_Childhood_Experiences_Study

87% of individuals who reported one ACE
reported at least one additional ACE.[6] The
prevalence of emotional abuse was 10.6%,
physical abuse 28.3%, sexual abuse 20.7%,
emotional neglect 14.8%, physical neglect
9.9%, mother treated violently 12.7%,
household substance abuse 26.9%, household
mental illness 19.4%, parental separation or
divorce 23.3%, incarcerated household
member 4.7%.
https://en.wikipedia.org/wiki/Adverse_Childhood_Expe
riences_Study

Dr. Karyn Purvis, Dr. David Cross, and Dr. Mandy Howard,
at the TCU Institute for Child Development
◦ Two months of pre-training which included readings, DVD’s and
written homework turned into the staff at TCU
◦ Sent in a Urine Sample!
◦ Adult Attachment Interview with one of the staff by phone
◦ 5 day training of TRBI
Three principles
Attachment theory
Mindfulness
Sensory Integration
Seizures
Dr. Wright- Talk on the effects of trauma on the developing brain, brain
chemistry and interpretation of our Neuro-chemistry panels
 Results of the AAI-Thank God I’m Healed Secure!







The Baby Fold agrees to do a research project
with Texas Christian University.
12 staff from TBF selected
Homework!
Training in Texas
Implementation
Results- Increased connection as evidenced by
improved Parent Relational Questionnaire Scores
◦ Parent’s comments regarding the skills they learned –
“Why didn’t we learn this before we adopted?”
◦ Child Welfare League of America www.cwla.org
•
•
•
•
•
 Trust-Based Relational Intervention (TBRI) for Adopted
Children Receiving Therapy in an Outpatient Setting by
Lauren E. Nielsen, Amanda R. Howard, Sheri R. Parris, Rob
Lusk, Kathleen Bush, Karyn B. Purvis, & David R. Cross

Addresses 3 areas
◦ Connection
 Building healthy, trusting relationships between child and
parents, mindfulness, teaches how to give and receive
nurture
◦ Empowerment
 Meeting the child’s physical needs (sensory, food, H2O)
 Environmental emotional safety
◦ Correction
 Proactive Strategies teach the child healthy behaviors
including self-regulation and social skills
 Responsive Strategies teach parents how to respond to
potential behavior problems
Physiology
Attachment
Self-Regulation
Competency

It’s very useful- just be aware that there are
many complexities that may need to be dealt
with along side of the trauma. Our kids and
families need a holistic approach.
◦ Developmental Delays
◦ Health issues
◦ Family dynamics- can be complex
 Parents with their own trauma
 Parents fear of other children in the home being hurt
 Aggressive children
 Sexually reactive children

Physiological issues that affect brain/emotional
development










Alcohol Related Neurodevelopmental Disorder
Autism Spectrum Disorders
Sensory Integration Disorder
Brain development issues that result in reduced functioningslower processing speeds/disabilities
Seizure Disorders
Severe mental health disorders such as Bipolar and
Schizophrenia
Medical issues such a untreated Strep
Medication side effects/ dulling of senses/loss of empathy
Allergies
Food sensitivities and parents who don’t understand nutrition
and fragile children
 Gut issues- diminished ability to process foods and create healthy
neuro-chemistry

Meeting Physical/Internal Needs (q2hrs)
◦ Hydration
◦ Food
◦ Sensory activities

Ecological Strategies
◦ Enhancing and modifying the environment to
support the child’s individual needs.
◦ Examples
 Carpet square
 Headphones

Engagement Strategies

Effectively gaining full attention of the child







close proximity
Giving full attention
Kind/sincere/playful facial expression
tone of voice
matching body language
position
Mindful questions
◦ What am I feeling?
◦ How does this child perceive my actions?
◦ How is the environment is influencing this situation?

Proactive Strategies

Responsive Strategies
◦ Teach skills during calm/alert times.
◦ Engage through playful activities and during nurturing
games and activities.
◦ When skills are taught proactively, the need for
responsive strategies are greatly reduced!
◦ Tools to be used for responding to challenging
behaviors – IDEAL Response
 Redoing the action again correctly
 Time In
 Creating learning opportunities so child sees you as “Coach”
verses “Warden”.




Immediate: respond within seconds
Direct: engage child directly
Efficient: only use the level of response
essential for addressing the challenge- if
playful redirection works- this is what you
should use
Action-Based: “re-do” to enhance body
memory

These are drawn from the E for Efficiency in
the IDEAL response.
◦ Lowest level possible- playful redirection or
reminder
◦ Parents learn to read their kid’s physiology




Eye movements
Breathing and heart rates
Connection
Mindful parenting is key
Parents make decisions based upon their assessment
of their child’s needs in the moment.

Assessment goes beyond the child
◦ Parent past Trauma
◦ Current Trauma originating with the child
 Parent has legitimate fear of the child harming others
or self
◦ Parent is not understanding (overwhelmed)
 Depression
 Too busy to implement (need to slow down and
connect)


Adopted children bring their strengths and
issues to the family. The parents bring their
own strengths and issues to the relationship
as well.
AAI: Healthy Attachment Style
◦ Do the parents have the ability to give and receive care,
negotiate needs, and are they autonomous?
◦ Family engagement is a key component of success
◦ Assessment of parent issues can be crucial to
success in a complex trauma case.
◦ New/untrained therapist
 Unaware of own Attachment Style
 Dismissive therapist may choose CBT with child over
experiential type therapies with families
 Under high amounts of stress
 Lack experience/may not be parent/ no stories
 Blames the parents instead of using therapeutic intervention.
◦ More experienced Therapist may need additional
Evidence based training




Unaware of own attachment style
Stress
Lacks success stories
Blames parents

We start with identifying healthy therapists
and hiring them.
◦ Healing attachment issues involves having healthy
relationships. If the therapist is not healthy they
can’t always help the parents and children heal.
 Starts in the interview- asking the therapist to select
out if they have issues, or intend to only work for us
for a short time.
 Support groups and supervision Frequent contact for support and reflective discussion
(Reflective Supervision)



Therapeutic Relationship/Engagement
Adult Attachment Inventory (created by Mary Main) or
an assessment of attachment style and the
competency of four healthy behaviors (give and
receive care, .
Modeling and Mentoring of emotional management
and Attunement practices (therapists need to
demonstrate, role play, model)
◦
◦
◦
◦

ARC activities (see back of the book)
Theraplay
Integrative EMDR (bilateral stimulation with Theraplay)
Trust-Based Relational Intervention (TBRI)
 Home Intensive Model as needed
Supportive Resources for Respite


Guided Meditation with Dan Siegel (Wheel of
Awareness) on Youtube
Dr. Dan Siegel - Books - The Mindful Brain
◦ Strive for emotional safety.
◦ Proactive strategies are more successful than
reactive. Children do not learn from punishment.



Tone
Volume
Cadence


Explore difficulties in this area by exploring
parent history and mentalizing the child’s issues
based upon their history
Adult Attachment Inventory-do the same thing
for the parents!
◦ Therapist may need to start these activities in small
increments based upon the child and parent’s comfort
level.
◦ Theraplay
 Nurture Group activities (borrowed from Theraply by TCU)
◦ Pull fun activities from The Out of Sync Child by Carol
Kranowitz

TBRI really stresses prevention of problems
through pro-active teaching of skills.
◦ Stick together- tie a loose string between caregiver
and a young child to remind them to stick with the
caregiver
 Remember Monkey backpacks?- not our favorite way
to control a child, but in this case the string is
something that can be held, honored, cared for by the
child
◦ Playing games that increase connection at the same
time a lesson is being taught

The California Evidence-Based Clearinghouse

FRIENDS National Resource Center
◦ www.cebc4cw.org/
◦ http://friendsnrc.org/
 Evidence-Based and Evidence-Informed Programs

Substance Abuse and Mental Health Service
Administration (SAMHSA)
◦ www.samhsa.gov
 Identifying and Selecting Evidence-Based Interventions

Child Welfare Information Gateway
◦ https://www.childwelfare.gov/
 Families and Communities: 2011 Resource Guide

Treating Traumatic Stress in Children and Adolescents
◦


Trust Based Relational Intervention resources can be found on their website:
http://child.tcu.edu/about-us/tbri/
Empowered To Connect
◦

By Margaret E. Blaustein, Kristine M. Kinniburgh
empoweredtoconnect.org/
Parent Engagement
◦
◦
www.howwelove.com/
Helpful books by Milan and Kay Yerkovich



Sensory Integration issues or Sensory Processing Disorder
◦

How We Love
How We Love Our Children
The Out of Sync Child by Carol Kranowitz
Food and gut issues
◦
◦
◦
www.spoonfoundation.org
GAPS: Gut and Psychology Syndrome by Dr. Natasha Campbell-McBride (Book)
http://www.westonaprice.org/
Feel free to contact Kathleen at
[email protected]