Hello. Welcome to episode 2 of the “Be A Neff” podcast.
Today were going visit this months theme Attachment as it pertains to the population children ages 3-10 years. In my experience this is where behaviors begin to materialize, especially between the ages of 3-5. It may be because they are entering school for the first time or are being put in a more structured environment.
In terms of diagnosis for the purpose of attachment disorder, we will review the behavioral definitions from the Wiley treatment planner “The Child Psychotherapy Treatment Planner”
Brought into the concerns the parent may be looking at are best looked through the diagnostic criteria outlined in the treatment planner.
What does this look like?The family complaints you will see when a child is struggling with attachment? Parents have all sorts of complaints. “Why doesn’t she listen to me?” “She doesn’t care I have tried everything.” “He’s destroying my house” “attitude”
The answers involve parent support, and the parents are most engaged at this point, the intake. My experience is they want to disengage at this point, and we do not want that. This is the time to encourage them to stay for the session by asking the child in session whether they would prefer a parent to stay for sessions. This builds trust and empowers a child, as kids don’t often get many choices and often are stuck with what others want around them. This helps by role modeling interaction with the parents, as deferring and allowing kids to make choices within limitations.
In a previous episode we reviewed the 4 separate attachment types and the way they appear in session. For the purpose of review they are anxious, fearful, avoidant, and secure. Our goal is to bring a client from either anxious, fearful, avoidant to secure attachment by role modeling a safe interaction and structure during each session. As a client engages with you you are best to divide the session into 3-4 parts that include opening, or grounding techniques, a review of the week or any struggles, problem solving the struggles, a new skill being introduced or revisited to manage any symptoms, and then close with a grounding exercise.This simple structure can be engaged and modified to meet the needs of your client in this moment but builds trust if it is consistently reviewed and respected in sessions.
Interventions
Actively build trust with consistent eye contact and being present with the client in session. Being present can include unconditional positive regard, reflective listening the clients language and motivational interviewing throughout the session after grounding work.
Complete an interview with the client to gain information in the clients perspective and how they experience daily life. I personally use “36 questions” app intimacy accelerator. This helps sort their personal values and what the client pays attention to.
Psychosocial evaluation to determine the strength of the childs stressors and trust in relationships around him.
Assess clients insight into the presenting problem, and willingness to work on problems out of session through homework.
Rule out other disorders(ODD ADHD Depression, etc)
Refer family to skills based programs to work on stress or problem areas that my be contributing to child's stress.
Elicit parents in co-joint sessions to be an active part of clients treatment, engaging in activities in the home throughout the day that build on the clients use of skills learned in session. Strategize with them to help come up with plausible solutions to conflicts in the home and build on clients skills.
Provide education to the parents on attachment and overall effect of trauma throughout the sessions through check ins.
Process with parents and authorities in the child's life the expectations.
1. Build trust through consistency and routine. Much like the therapy session itself, provide education to the parents that beginning the day with a simple routine and reviewing it will build trust with the child. Give them 1 thing to look forward to, outside of normal routine if possible and a reasonable time when it will happen. “We will go out to the park after breakfast.” “We are going to lunch with grandma”. Are good examples.
2. Showing warmth and affection. To build trust that you are a safe person, you need to consider the 2 to 1 ratio to begin with. Instruct the parents that a confused child does not trust, and having more positvie than negative interactions is the foundation to build trust, even when a child isn’t showing positive interactins back, the ratio of interacting needs to be more positive than negative. The baseline for verbal praise needs to start low, such as following a simple prompt, and building from there.
3. Sensitivity to sounds. Be aware of your clients sensitivity to sounds, and apologize when you make a loud sound. Shutting the door loudly can even be a trigger, but quickly apologizing and role modeling taking a deep breath or letting the client breathe for a moment and ground themselves with your help can start the session in a much better place.
13.Alert to upcoming activities. Part of the daily review in therapy could be mentioning a holiday that is coming up or an anniversary, asking how the client celebrates. If there doesn’t appear to be anything on the calendar, I often ask silly quesitons like “whats new in your zoo?”
4. Illusion of choice, often times in building momentum with a child, I may offer a choice that isn’t a choice at all, but there is an A and a B so kids go with it. “Allan, do we want to race to the swings or do we want to walk.” Either way were going to the swings, make sure you explain your choices to the parents, who are sometimes confused whats happening at this point and why their normally difficult to transition kid is walking so easily through the playground. They will appreciate this little secret. ;)
5. Speak simply and repeat yourself at least once. There's a reason that kids don’t sit still for long times and big words don’t seem to amaze them like they do parents. Kids need concepts they understand, and aren’t motivated to get to the point where they do, they will do waht kids will do at the point you start talking around them, they will look for a way to play. If you want to engage with a kiddo, you need ot keep it short and sweet.
6. Ask the client to be a good leader, and show how to lead. When possible identify who the kid is bigger than in their household or their life, and encourage them to lead those around them. Ask them what they want to be when they grow up and look for ways they can grow in skills they might need as an adult. For instance if they say military or police man, we can talk about what their job would be like, and play pretend that they were in that job now. 7. Food insecurity is a real issue for a child that doesn’t have trust. We might see this behavior in hiding or hoarding food, eating quickly or stealing food or just being fearful around mealtimes. The best intervention for this is providing healthy snacks the kids can have at any time, such as a fruit bowl and consistently having the bowl replenished 1-2 times a week as needed. Kids have amazingly high metabolisms, so I would also provide psychoeducaiton to the parents about what this need is and how we can fill it. The mathematical algorithym for trust is T(trust)=Behaviour/time. So if every day there is food in the bowl, they will learn over time that this won’t dissapear. This applies to all behaviors, but food and sleep are the bottom tier needs for safety and low hanging fruit for a therapist. Solve these low tier behaviors for maslows triangle leads to the next intervention.
8. HALT. I teach all my parents halt. Hungry, Angry, Lonely, Tired. Before doing anything else, a parent has to stop and assess halt. If all those needs are met then they are working with a child with optimum compliance. Otherwise you need to meet those needs before asking for anything else. Truth this concept really does apply to everyone. No one is at their best when they are hungry, angry, lonely or tired.
9. Values. Values card sort. Create or google a list of values and write them on small index cards. Have 3 cards set aside marked “important to me” “very important to me” and “not important to me” have the client sort the cards into these 3 piles and then pull all but the very important to me. Have them keep only 10, then review them asking open questions such as “why is x so imporant?” “how did this make your top 10?” Then have them sort them in order, closet to them being most important, and take a photo. Celebrate that these are their values, things that are non negotiable in their lives and meaningful. When the client is really stuck on a problem later in the session, refer back to these values. We live with our values and we are happiest.
Introducing Technology
Turning now adding technology, I wonder how many of my peers have ever introduced gaming in the office? When I look at the aspects of gaming, i’m often really delighted that game designers now are listening to parents and others in the community and introducing whats called “prosocial points” in their games, which have features that increase engagement and award points for behaving in a way that brings people towards the value of social interaction. The developers at http://ithrivegames.org/2019/05/07/introduction-to-ithrives-clinicians-guides/ specifically have done an awesome job curating both a peer reviewed journal that I’m excited to be getting a copy of soon and clinician guides available for free on their website that introduces us to games and their prosocial value. These will be linked in the blog, all available for free, at www.ithrivegames.org. This just makes me so excited, working with as many teens as I do, in building engagement.
Closing thoughts
I appreciate you joining me today and look forward to interacting on instagram and facebook @mytherapies or through the hashtags #topeka #anxiety #therapist and strive to respond to every post. Thank you for joining us. Interested in meeting with us live? This months podcast is sponsored in part by the 2019 KACAP Conference on Poverty. The Kansas Conference on Poverty brings together direct service workers, agency/department management, agency Boards of Directors, volunteers and anti-poverty advocates from Kansas’ non-profit organizations, faith-based agencies and government offices. Join us at the Capital Plaza Hotel in Topeka, Kansas on July 17th and 18th in our live workshops. This year’s conference theme is “Working Towards Prosperity”. I really enjoy this conference, it will be my 3rd year attending and 2nd year speaking. Each year I discover new resources to add to my referral list, and make friends with excellent people doing great things in my state. When you are in the business of solving problems and making change, you sometimes need to recharge your batteries and give back to other workers. We hope to see you live and in real life, and welcome you to our community of change makers!
This episodes reading cojoint with the podcast and post test combine to provide .5 CE as part of a live continuing education lecture. To receive credit please purchase the post test here. After purchase you will be redirected to the post test and quiz, and issued a certificate. This is part of a 4 part series and will culminate to a full post test released week 4. Thank you for taking the time to listen and join us.
Reference
Jongsma, A. E., Peterson, L. M., & McInnis, W. P. (2014). The Child Psychotherapy Treatment Planner (5th ed.). John Wiley & Sons. p.66-71
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