4/16/2014
Rethinking Therapeutic Work:
Transdisciplinary Therapy in
Infant-Family & Early Childhood Mental Health
Dr. Kristie Brandt
All rights reserved. Do not copy, reproduce, distribute, or disseminate this document
in any way without express written permission from the author.
LEARNING OUTCOMES
As a result of this training, participants will:
1. Be able to describe the elements of “Evidence-Based
Treatment” & “Evidence-Based Practice.”
2. Have an improved ability to examine research results
and translate findings into clinical interventions.
3. Develop greater skills for assessing therapeutic
potential in a child’s daily contexts and leveraging this
potential to advance therapeutic goals.
4. Be able to identify trans-disciplinary therapeutic
interventions for working with children and
establishing a therapeutic plan.
Core Concepts in
Infant-Family & Early Childhood
Mental Health
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Give children a predictable, low
stress, loving environment,
with nurturing and
safe relationships.
5 ESSENTIAL INGREDIENTS
FOR OPTIMAL INFANT & EARLY CHILDHOOD
MENTAL HEALTH AND OVERALL DEVELOPMENT
1. A Safe, Healthy & Nurturing Pregnancy
2. The Opportunity & Ability to “Fall in Love with”
and “Be in Love with” Safe & Nurturing Adult
3. Support in Learning to Self-Regulate
4. Support in Learning to Mutually Regulate
5. Nurturing, Contingent & Developmentally
Synchronized Care
Genetics & Epigenetics
The baby’s epigenome is being shaped
extensively during pregnancy and in
the early years of life.
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The Process of
Neurodevelopment
How do prenatal
& childhood
experiences
impact the
brain?
Neurons: The Building Block of the Brain
Dendrites
Soma &
Nucleus
Axon
Neurons
A newborn has about 100
billion neurons at birth
Most of them are not
connected to other
neurons
Neurons cannot work
alone and need to
connect to other neurons
Rethinking the Brain, 1997
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Development of Synapses
• At birth, most of the neural networks in the
brain are undeveloped
• From birth to 8 months, there is an explosive
increase in the number of synaptic
connections
• The highest density and highest absolute
number of synapses is in the first year of life
Bruce D Perry © 2010
The Process of Neurodevelopment
Neurogenesis
Migration
Differentiation
Apoptosis (cell death)
Arborization
Synaptogenesis
Synaptic Sculpting
Myelination
Bruce D Perry © 2010
The Process of
Neurodevelopment
What is the evidence of
disruption in this process?
Development, Behavior,
Health & Functioning
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Evidence from the
ACE Study Suggests:
“Adverse childhood experiences
are the most basic cause of health
risk behaviors, morbidity, disability,
mortality, and healthcare costs.”
www.cdc.gov/NCCDPHP/ACE
Anda & Felliti
Childhood stress and adverse circumstances
negatively impact lifelong health and well-being.
Adverse Childhood Experience (ACE) Study
www.cdc.gov/nccdphp/ace
(Anda & Felitti)
Adult Adverse Experiences (ACE) =
childhood abuse, neglect, and exposure to other
stressors (e.g. called names, hungry, dirty clothes,
felt unloved or unprotected, harshly spanked).
As the ACE score increases, the risk for the
following mental health problems
significantly increases:
Growing up experiencing any of the following
conditions in the household prior to age 18:
•
•
•
•
•
•
Recurrent physical abuse
Recurrent emotional abuse
Sexual abuse
An alcohol and/or drug abuser in the household
An incarcerated household member
Someone who is chronically depressed, mentally ill,
institutionalized, or suicidal
• Mother is treated violently
• One or no parents
• Emotional or physical neglect
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Growing up experiencing any of the following
conditions in the household prior to age 18:
•
•
•
•
•
•
•
•
Feeling unloved/unprotected
No enough to eat/being hungry
Dirty clothes
Called hurtful names or insulted
Harshly spanked
Sworn at, insulted or put down
Thinking parents wished you weren’t born
Threatened with physical violence
The researchers found that people with 6
or more ACEs died nearly 20 years earlier
on average than those without ACEs - -
60.6 years versus 79.1 years
The Number of ACEs Directly Correlate with:
• Alcoholism/alcohol abuse
• Depression
• Drug Addiction & Illicit drug use (adult & adolescent)
• Smoking (adult & adolescent)
• Suicide attempts (adult & adolescent)
• Anxiety Disorders
• Risk for intimate partner violence
• Autobiographical Memory Disturbances
• Hallucinations
• Work Absenteeism
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• COPD
AND THE FOLLOWING
• Obesity
HEALTH CONDITIONS
• Fetal death
AND HEALTH RISKS…
• Liver disease
• Type II diabetes
• Adolescent pregnancies
 Multiple sexual partners
 Unintended pregnancies
 Ischemic heart disease (IHD)
 Health-related quality of life
• Early initiation of sexual activity
• Sexually Transmitted Infections
EXPOSURE TO VIOLENCE AND OTHER STRESSORS DURING
CHILDHOOD IS ASSOCIATED WITH TELOMERE EROSION FROM
5 TO 10 YEARS OF AGE: A LONGITUDINAL STUDY;
MOLECULAR PSYCHIATRY; SHALEV, ET AL.
TELOMERES
PROTECT THE ENDS OF THE CHROMOSOME
FRAYED TELOMERES ARE ASSOCIATED WITH CHRONIC DISEASE,
PREMATURE AGING WITH CHRONIC DISEASE ONSET, AND EARLY DEATH
“Compared with their counterparts, the children who
experienced 2 or more kinds of violence exposure showed
significantly more telomere erosion by age 10…”
“…early experiences help to
determine brain structure, thus
shaping the way people learn, think,
and behave for the rest of their lives.”
I Am Your Child
Reiner Foundation
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In pregnancy, infancy and early
childhood, the foundation for optimal
DYADIC FUNCTIONING
is being established within 10
Key Systems and capacities.
These Key Systems are open,
sensitized, and destabilized…
Infant Mental Health Key Systems
1. Neurodevelopmental - epigenetics, predictable care, stress mgmt
2. Attachment System - protection, safety & love
3. Regulatory System - self & mutual regulation, patterns of care
4. Somato-Sensory System – body, affect & senses
5. Memory System - implicit, explicit, procedural, autobiographical
Brandt, K. Core Concepts in Infant-Family and Early Childhood Mental Health. In Brandt,
Perry, Seligman & Tronick (Eds): Infant & Early Childhood Mental Health: Core Concepts
and Clinical Practice. American Psychiatric Press, Inc. 2014
Infant Mental Health Key Systems
6. Behavioral System - cueing & gesturing
7. Meaning-Making System - general & specific
8. Relational System - engagement, responsivity & contingency
9. Mentalization System - reflection of the state of self & other
10. Intersubjective System - shared dyadic mental states
Brandt, K. Core Concepts in Infant-Family and Early Childhood Mental Health. In Brandt,
Perry, Seligman & Tronick (Eds): Infant & Early Childhood Mental Health: Core Concepts
and Clinical Practice. American Psychiatric Press, Inc. 2014
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Attachment = Protection
Protection = Safety
Safety is essential for
optimal development.
A child’s development is
negatively impacted
when a child does
not feel safe &
protected.
The Lasting Impact of Early
Childhood Experiences
For optimal development,
children need support in
learning to self-regulate
Low
Stress Arousal
Abstract Thought
Concrete Thought
Constructed Ideas
Collaboration
Emotional Reactivity
Attachment
Pleasure/Reward
Circadian Rhythms
Reflexive Behaviors
Appetite/Satiety
Arousal Regulation
Motor Regulation
State Regulation
High
P LASTICITY
Achieve & Maintain
States of Consciousness
All rights reserved. Bruce D. Perry, 1998©
WWW.CHILDTRAUMA.ORG
Heart Rate
Blood Pressure
Breathing
Body Temp
Metabolism
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ADAPTIVE
RESPONSE
Rest
Vigilance
Freeze
Flight
Fight
AROUSAL
Rest
Vigilance
Resistance
Defiance
Aggression
Extended
Future
Days
Hours
Hours
Minutes
Minutes
Seconds
Loss of Sense
of Time
Calm
Alert
Alarm
Fear
Terror
Neocortex
Subcortex
Subcortex
Limbic
Limbic
Midbrain
Midbrain
Brainstem
Brainstem
Autonomic
Reflexive
SENSE OF TIME
MENTAL
STATE
BRAIN
AREAS
COGNITION
Abstract
Concrete
Emotional
Reactive
FUNCTIONAL
AGE
>15
8-15
3-8
1-3
0-1
HEART RATE
70-90
90-100
101-110
111-135
136-160
ALL RIGHTS RESERVED; BRUCE D. PERRY, 1998. USED WITH
PERMISSION.
Basic Concepts of Regulation
Primary Regulation is the ability to process and
manage sensory input in order to progressively:
•
Attain and maintain states of consciousness
•
Attain & maintain moods (e.g. calm)
•
Manage behavior, reactions & responses
•
Choose levels of engagement, responsivity & interaction
Kristie Brandt
Regulatory Supports
Managing Sensory Stimulation
Extroceptive • Smell (Olfactory)
Interoceptive
•
•
•
•
•
•
•
Hearing (Auditory)
Visual (Sight)
Taste (Hearing)
Tactile (Touch)
Vestibular (Balance)
Proprioceptive (Movement)
Inner Sense (Organ movement, nausea, hunger, etc.)
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Recognizing
regulatory efforts &
abilities can enhance
respect, scaffolding
& support for the
expansion of
regulatory
capacities.
Supporting Regulation is not Changing Regulation!
Support in
learning to
mutually
regulate.
The infant and parent/caregiver use
one another to regulate
- - prolong or change - states of consciousness, find a co-created
state, and manage response to stimulation.
Mutual Regulation
Achieving &
maintaining warm,
loving connections
with parents fosters
the desire for more
warm, loving
connections.
Dr. Kristie Brandt © 2007
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Mutual Regulation
Includes
Mis-Matches & Repairs
The Process of
Development
IDEAS
SKILLS
JUDGEMENT
The Progression of Parental
Response to the Child’s
Developmental Agenda
• Embrace it
• Set Limits/Discipline
• Punish
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WHAT/WHO INFORMS YOUR WORK?
•
Ayres – Sensory processing & sensitive caregiving
•
Barnard - Responsivity & cueing
•
Brazelton - Individual differences
•
Bowlby & Ainsworth - Attachment
•
Erickson - Trust and autonomy
•
Fonagy - Attachment/exploration axis
•
Fraiberg – Ghosts in the nursery
•
Freud - Satisfying oral and anal needs
WHAT/WHO INFORMS YOUR WORK?
•
Gerber - Respecting the infant’s process of becoming
•
Mahler - Separation/individuation
•
Montessori - Absorbent mind & sensory learning
•
Piaget - Emergence of thought
•
Rubin - Taking in/taking hold & immersion in the baby
•
Sander - Affective presence
•
Stern - Core sense of self emerges & affirming matrix
•
Tronick - Mutual regulation model
How do we grow
new neurons?
Loving Relationships
Exercise
Novelty
Space
This process is supported by:
Phytonutrients, Reduced Stress & Restorative Rest
How do we enhance synaptogenesis?
Repetition…Repetition…Repetition
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HEALING:
“It is not what has happened to you, but how you
make sense of what has happened to you.”
Dan Siegel
Primary Principle of IPMH Therapy:
“Therapy is not about erasing the old stuff…
it is about creating new, positive experiences.”
Bruce Perry
Dr. Kristie Brandt © 2007
“Self-correcting
tendencies and energy for
adaptation are probably
stronger in this early
period…than they will
ever be again.”
Brazelton, 1981
Who is a Therapist?
Anyone who works to restore or
maintain health and well-being.
What is the adjective before “therapist”?
Dr. Kristie Brandt © 2007
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Given what we know…
What is Therapy for
infants & young children?
BASIC CONTEXT FOR CHILD THERAPY
The child’s ability to achieve optimal
social-emotional, cognitive, and physical
development is dependent upon:
• Play
• Exploration
• Interaction with others
• “Falling in Love” & “Being in Love” with a
safe and nurturing adult
• Finding “mutual delight”
Therapy is anything that
reduces prenatal stress.
Therapy is anything that reduces
parental and child stress, and
supports joy and safety for
children & families.
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Therapy is anything that brings or
keeps healthy, safe and nurturing
adults in a child’s life.
Therapy is anything that works to reduce or
eliminate Adverse Childhood Experiences.
Dr. Berry Brazelton:
“Our job is to give parents what
they need to do the best they can
by their kids…” so…
Therapy is anything that
supports parents in
“doing the best they
can by their kids.”
Warning!
The Side Effects of Replacing
Evidence-Based Practice with
Evidence-Based Treatments
Kristie Brandt
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EBT Lists
Example:
Programs in the SAMHSA
National Registry of EvidenceBased Programs & Practices
for Children Age 0-5 a Total of 20
(6 described here)
Power Point by Dr. Kristie Brandt; 2011
http://www.nrepp.samhsa.gov/AdvancedSearch.aspx
PROGRAM
AGE
FOCUS
SETTING
PRACTITIONER
1.
Active
Parenting
Now
2-12y
Video-based parent education
classes with video vignettes and
discussion on parenting led by a
trained facilitator;
One 2-hour class per week for 6
weeks
School-based
Home
Community
Any profession
(with training)
2.
Al’s Pals:
Kids Making
Health
Choices
3-8y
School-based
46-week interactive prevention
program that seeks to develop
social-emotional skills such as selfcontrol, problem-solving & healthy
decision-making in children, and
reduce bullying, harms of
substance use, etc.
Classroom
teachers
(with training)
3.
Child-Parent
Psychotherapy
(CPP)
0-5y
(child)
Psychotherapy-based treatment of Home
children with at least 1 traumatic Out-patient
event; focus is to strengthen
child’s sense of safety, attachment
& appropriate affect, and improve
cognitive, behavioral & social
functioning.
Psychotherapists
(with training)
to 55
(Parent)
(FOR STUDY: WEEKLY PSYCHOTHERAPY
FOR 1 YEAR)
SESSIONS
PROGRAM
AGE
FOCUS
SETTING
PRACTITIONER
4.
Children in
the Middle
0-18y
An educational intervention for
divorcing families with 1-2 live or
online classes 90-120 minutes
each
Community
based setting or
online
Multiple disciplines
including teachers,
counselors,
principals, etc.
5.
DARE to
be You
(DTBY)
2-5y
Prevention program for high-risk
families with children
2 to 5 years focused on
on children's developmental
attainments and aspects of
parenting that contribute to youth
resilience and later decrease
substance abuse; Families meet
for 10-12 weekly sessions over 3-4
months for 2 hours of workshops
plus a family meal
Community
settings
Multiple disciplines;
leaders must
attend training
seminar
6.
Families &
Schools
Together
(FAST)
0-18y
Multifamily group intervention to
build relationships with families,
schools & communities to increase
well-being of elementary school
children, prevent school failure,
prevent substance abuse;
8 weekly classes then monthly for
years
School-based
Other
Community
settings
Multiple disciplines;
community leaders
must attend
training seminar
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DAVID SACKETT'S DEFINITION (2000)
Evidence Based Practice (EBP) is the
conscientious, explicit and judicious use of current
best evidence in making decisions about the care of
individual patients. EBP requires the integration of
clinical expertise with the best available clinical
evidence and the patient’s values and preferences.
Power Point by Dr. Kristie Brandt; 2011
"Evidence based practice is an
approach to decision making in which
the clinician uses the best scientific
evidence available, in consultation with
the patient, to decide upon the option
that suits the patient best.“
Gray Muir , et al., 1997
Power Point by Dr. Kristie Brandt; 2011
Steps of EBP (Gibbs, 2003)
BECOME MOTIVATED TO APPLY EBP
•
Step 1: Convert information need (prevention, assessment,
treatment, risk) into an answerable question.
•
Step 2: Track down current best evidence.
•
Step 3: Critically appraise the evidence.
•
Step 4: Integrate critical appraisal with practice experience,
client’s strengths, values, and circumstances.
•
Step 5: Evaluate effectiveness and efficiency in exercising
steps 1-4 and seek ways to improve them next time.
•
Step 6: Teach others to follow the same process
Power Point by Dr. Kristie Brandt; 2011
Gibbs, 2003
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WHAT IS NEEDED TO MAKE EBP WORK
EBP requires:
•
•
•
•
Training in search techniques
Training in critical appraisal
Computer resources
Other electronic resources
Power Point by Dr. Kristie Brandt; 2011
Edward Mullen & Aron Shlonsky
September 22, 2004
Challenges of EBTs in the Inter-Disciplinary InfantParent & Early Childhood Mental Health Field
• Published research rarely addresses the
relevance of an EBT across complex amalgams of
service delivery setting, child chronological &
developmental age, parent & parent-child
attachment status, child & parent history, neurorelational functioning, cultural variation, parental
capacities, and levels of case complexity .
Mullen & Sholonsky, 2004
Power Point by Dr. Kristie Brandt; 2011
Without a thorough, comprehensive,
inter-disciplinary assessment ,
treatments may be selected for children,
parents, families and/or dyads
that could be ineffective,
inappropriate, or even harmful.
Power Point by Dr. Kristie Brandt; 2011
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• Important not to assume that treatments
that have not been studied are
ineffective
• Good practice and science calls for the
testing of practices
• Barriers to both conducting and
publishing research should be addressed
Report of the APA Presidential Task Force on EBP in Practice
Ronald F. Levant; 2005 APA President
Power Point by Dr. Kristie Brandt; 2011
EBTs are not a substitute for
training in building a relationship
with the client.
Chambless & Hollon, JCCP, 1998)
Evidence does not make
decisions, people do
Haynes & Devereaux; BMJ; 2002
Power Point by Dr. Kristie Brandt; 2011
Training Challenge…
IMH professionals must be
prepared and educated for
Evidence-Based Practice (EBP)
and not merely for the practice of
Evidence-Based Treatments
Power Point by Dr. Kristie Brandt; 2011
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There is a distinction
between the
“evidence user”
and the
“evidence-based practitioner.”
Upshur & Tracy; Oxford University Press; 2004
Power Point by Dr. Kristie Brandt; 2011
“Evidence-users”
accept evidence that has been vetted
by others – thus replacing one
authority for another.
What is the basis for the authority of
the evidence appraisers?
(Mullen & Shlonsky, 2004)
Power Point by Dr. Kristie Brandt; 2011
Definition of Evidence Challenge
Because contemporary health care and
human services are multidisciplinary,
there are many differing perspectives
that require consideration…
Accordingly, the concept of a single,
restrictive understanding of evidence is
not sustainable.
Power Point by Dr. Kristie Brandt; 2011
Edward Mullen & Aron Shlonsky
September 22, 2004
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EBP STARTS WITH THE
PATIENT AND ASKS:
What research evidence will
assist in achieving the best
outcomes for this patient?
Power Point by Dr. Kristie Brandt; 2011
Report of the APA Presidential Task Force on EBP
Ronald Levant; 2005
EBP ENCOMPASSES A BROAD
RANGE OF CLINICAL ACTIVITIES:
A decision making process for
integrating multiple streams of
research evidence into the
intervention process
Power Point by Dr. Kristie Brandt; 2011
Report of the APA Presidential Task Force on EBP
Ronald Levant; 2005
A Mobius Care Model
Mobius:
• HAS NO BEGINNING POINT AND NO ENDING POINT
• CONTINUOUS FROM ANY POINT OF ENTRY
Kristie Brandt; All rights reserved. Do not copy, reproduce, distribute, or disseminate
this document in any way without express written permission from the author.
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CARING FOR AN INFANT IS MOBIUS CARE
It is fluid and continuous, without
a start or end point to the day or week.
Optimally, a baby is always being looked after
by an adult who understands and can support
the baby’s developmental needs.
Kristie Brandt; All rights reserved. Do not copy, reproduce, distribute, or disseminate
this document in any way without express written permission from the author.
The
Tile & Grout
Approach
Translating Concepts from
Neurobiology into Therapeutic
Interventions for Young Children
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GUIDING
SUPPORT RAILS
Congnitive Development
Floortime, ABA & Discreet Trials
PSYCHOPHARMACOLOGY
Sleep Studies & Therapies
NEUROBIOLOGY
Phytonutrient Therapies/Nutrition
PSYCHOPATHOLOGY
CORE
CONNECTING
CONCEPTUAL
CROSS
TIES
Pharmaceutical/Medication Therapies
GRIEF & LOSS CONCEPTS
OT , PT, SLP Therapies
SPECIAL NEEDS
Sensory Processing Therapies
TRAUMA & MALTREATMENT
EMDR
FAMILY SYSTEMS
Environmental Therapies
SOMATIC PROCESSES
Educational Therapies
EPIGENETICS
Meditation, Mindfulness & Prayer
PSYCHODYNAMICS
SOLIDLY
SUPPORTED
TRACK BED
STRATEGIES
Sand Play & Sand Tray
THEORIES & PROCESS OF CHANGE
Massage & Touch Therapies
MENTALIZATION
Music & Tonal Therapies
NEURODEVELOPMENT
Dance & Movement Therapy
RELATIONAL SYSTEM
Play,MArt
& Drama
Therapies
EANING
MAKING
MEANING MAKING
Video Intervention Therapy
ATTACHMENT SYSTEM
Somatic & Body-Based Therapies
BEHAVIORAL SYSTEMS
Psychotherapy Approaches
REGULATORY SYSTEMS
Relationship-based Therapies
DYADIC FUNCTIONING
Brandt,
2009
WHAT IS A CHILD’S AGE?
•
•
•
•
Chronological
Adjusted
Developmental
Functional
Kristie Brandt; All rights reserved. Do not copy, reproduce, distribute, or disseminate
this document in any way without express written permission from the author.
UNDERSTANDING DEVELOPMENTAL SEQUENCES
Examples:
Motor – turn over, sit up, crawl, pull up, cruise, walk, run; more
subtle – overcoming the tonic neck reflex, vestibular processing, trunk tone,
autonomy, overcoming the plantar reflex, etc.
Turn Taking
– suck/pause, back and forth games, slowed
response by caregiver to calls for assistance (waiting), thwarting,
impulsivity/self-regulation, empathy, Theory of Mind, fairness…
Transitions – mutual regulation, state transition support (e.g.
awake to asleep or asleep to awake), routines, environmental
cueing, tolerance of the unexpected, self-regulation…
Play – safety, self-play, patterned play, play with violation of
pattern (e.g. peak-a-boo), parallel play…
Kristie Brandt; All rights reserved. Do not copy, reproduce, distribute, or disseminate
this document in any way without express written permission from the author.
24
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Children that exhibit externalizing behaviors are usually
categorized into specific DSM-IV diagnostic categories:
Hyperactive/Hypervigilant/Distracted/ Impulsive:
ADHD
Aggressive Behaviors:
Oppositional Defiant Disorder
Delinquent Behaviors:
Conduct Disorder
Kristie Brandt; All rights reserved. Do not copy, reproduce, distribute, or disseminate
this document in any way without express written permission from the author.
Creating
“Mobius Therapy”
for Adam
What did Adam miss? When? Why?
How can we reproduce what he
missed in an age-appropriate way?
Kristie Brandt; All rights reserved. Do not copy, reproduce, distribute, or disseminate
this document in any way without express written permission from the author.
Therapeutic = NMT Informed Developmentally
Appropriate Therapy (DAT):
1.
Specific and identified
therapeutic intent
2.
Therapeutic goals
3.
An identified and qualified
(or informed) therapist
Following in color are the portions of Adam’s
168 hour week that were NMT DAT…
Kristie Brandt; All rights reserved. Do not copy, reproduce, distribute, or disseminate
this document in any way without express written permission from the author.
25
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Goal for Trauma Focused
Cognitive Behavioral Therapy (TF-CogB)
• Teaching children and their non-offending caregivers adaptive
coping skills
• Assisting children to emotionally and cognitively process their
traumatic experiences
• Reducing emotional and behavioral reactions exhibited by children
• Facilitating children's adjustment to placement when needed
• Assisting non-offending caregivers in responding to their child's
reactions and helping them cope with their own feelings related to
the trauma(s)
• Working with caregivers and children in joint sessions to improve
interaction, enhance communication and practice personal safety
skills to help reduce the risk of future victimization
Retrieved from http://www.caresinstitute.net/services_trauma.php on 10-10-11
FAMILY PSYCHOTHERAPY GOALS
• Enhance how Adam and his mother relate and function as
a family group
• Support mother and son in understanding and modifying
problematic or dysfunctional patterns of interaction
• Help mother and son to communicate and interact more
effectively
• Identify coping strategies for each individual and the dyad,
and support them in appreciating where these can be
useful and where they can create conflict
• Support mother and son in non-violent conflict
management
• Reduce Adam’s externalizing behaviors
(Goals came directly from the psychotherapist)
Therapist: PhD/Clinical Psychologist
Therapy type: Interpersonal Psychotherapy
Goal
Increase the portion of
Adam’s week that is
“Therapeutic”
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Goals of Student Farm Therapy
1. Reduced stress levels
(Nielsen & Hansen, 2007)
2. Positive neuroendocrine & affect
support, decreased cortisol
(Van Den Berg & Custers, 2011)
3. Physical fitness/exercise
4. Better nutrition (increase the amount
and variety of vegetables eaten)
(Ratcliffe, et al., 2011)
5. Sunlight exposure + impact on mood
6. Develop “parallel play” capacities
7. Interface with safe & nurturing adults
“The presence of
animals, and interaction
with animals, decreases
physiological indices
such as heart rate and
blood pressure, and
improves psychosocial
variables (e.g., reduces
anxiety) in both patients
and healthy persons.”
Cole, Gawlinski, Steers & Kotlerman. 2007.
American Journal of Critical Care. 2007;16: 575-585
Therapeutic Goals for Time with Grandparents
1.
2.
3.
4.
5.
6.
Support Adam in forming a stronger connection with
safe and nurturing adults, and strengthen kinship ties
Develop or strengthen the foundational capacities for:
(1) Turn-Taking; (2) Sustained Attention; (3) Mutual
Responsiveness; (4) Match/Mis-Match & Repair;
(5) Clear Cue Giving & Receiving; and, (6) Co-creation
of dyadic states of consciousness
Experience the attention of another
Provide variety and expand tolerance for different
social setting, shared activities, conversation, triadic
engagement, and joint attention
Enhance nutrition
Support socialization and play
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Therapeutic Goals for Time at BGCA
1.
2.
3.
4.
5.
6.
7.
Increase physical activity to support proprioceptive
feedback for core regulation and promote good health
Enhance neuro-functioning through novel activities that
require navigational skills, visual/spatial skills, crossmidline coordination, motor planning & agility
Enhance self-regulatory capacities (martial arts, music, art)
Reduce anxiety through repetitive activities and
expressive arts
Increase reading skills to enhance confidence in school
Increase range of social contexts and contact with safe
and nurturing adults
Support socialization and play
Kristie Brandt; All rights reserved. Do not copy, reproduce, distribute, or disseminate
this document in any way without express written permission from the author.
STAGES OF PLAY DEVELOPMENT
• Solitary Play: 6-18 months
• Parallel Play: 18-36 months
• Group Play: >3 years (associative/cooperative)
• Cooperative Team Play
Where might Adam’s “Play Development”
have been derailed and why?
Kristie Brandt; All rights reserved. Do not copy, reproduce, distribute, or disseminate
this document in any way without express written permission from the author.
Therapeutic Goals for
Dedicated Time with Mother
1. Help mother and son “fall in love” and stay in love
2. Achieve moments of “Mutual Delight”
3. Support rhythmicity, predictability, and
organization of each day
4. Enhance current mother-child contact that is
reminiscent of the common contact point in the
early relationship of feeding/eating to support
positive associations with engagement and
interaction around eating
Kristie Brandt; All rights reserved. Do not copy, reproduce, distribute, or disseminate
this document in any way without express written permission from the author.
28
4/16/2014
Therapeutic Goals for Portion of Day for
Media & “Down Time Alone”
1. Organize and provide limits or guidelines for electronic
media; this begins the reconstruction of limit setting
and boundaries established by mom, and helps Adam
learn self control
2. Provide support for state regulation and state transition
for sleep
3. Cultivate tolerance of “choice” and thwarting
4. Support development of skills for “time in” with self
(e.g. reading, drawing, day dreaming, thinking, solitary games, etc.)
Enhancing Deep, Restorative Sleep
•
•
•
•
•
•
•
•
•
Sleep routine
Sleep music
Air Filter with white noise
Temperature regulated
Comfortable bed & bedding
Window covering for privacy
Window covering to darken
Secure locked windows
Reassurance
(attachment-based safety)
THE BODY’S CLOCK: SUPRACHIASMATIC NUCLEUS (SCN)
• The SCN is 2 pinhead-sized brain structures each having
about 10,000 neurons in the hypothalamus, just above the
point where the optic nerves cross
• Light on the retina is received by photoreceptors in the
retina and moved along the optic nerve to the SCN
• Signals from the SCN travel to the pineal gland, that
responds to light by switching off production of the
hormone melatonin that usually begins to rise at dusk
• The body's level of melatonin normally increases after
darkness falls, making people feel drowsy
• SCN influences sleep/wake cycles, body temperature,
hormone secretion, blood pressure changes, and more
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4/16/2014
ALL NINDS-PREPARED INFORMATION IS IN THE PUBLIC DOMAIN AND MAY BE FREELY COPIED;
NIH PUBLICATION NO.06-3440-C; MAY 21, 2007
Training for Adam’s “Therapists”
• As much about Adam’s history as Caroline desired to share
• Basics of the NMT
• Concepts about the arousal continuum and related cues &
behaviors
• Support in thinking about their own arousal response patterns
• Basics of attachment and “falling in love”
• Child development concepts and Brazelton’s Touchpoints
• The specific goals for their time with Adam
Later, each “therapist” worked in the collaborative to
assess progress and plan new goals.
Sun
Mon
Tue
Wed
Thu
Fri
Sat
6a-7a
7a-8a
8a-9a
SPEC ED STUDIES SPEC ED STUDIES
9a-10a
SPEC ED STUDIES SPEC ED STUDIES
INDEPENDENT
STUDY
IN LIBRARY
10a-11a
SPEC ED STUDIES SPEC ED STUDIES
IN LIBRARY
11a-12n
SPEC ED STUDIES SPEC ED STUDIES
IN LIBRARY
12n-1p
SPEC ED STUDIES SPEC ED STUDIES
IN LIBRARY
1p-2p
SPEC ED STUDIES SPEC ED STUDIES
IN LIBRARY
ALONE
ALONE
ALONE
ALONE
ALONE
SPEC ED STUDIES SPEC ED STUDIES
SPEC ED STUDIES SPEC ED STUDIES
WATCHED BY
15YO NEIGHBOR
SPEC ED STUDIES SPEC ED STUDIES
WATCHED BY
15YO NEIGHBOR
SPEC ED STUDIES SPEC ED STUDIES
WATCHED BY
15YO NEIGHBOR
SPEC ED STUDIES SPEC ED STUDIES
WATCHED BY
15YO NEIGHBOR
SPEC ED STUDIES SPEC ED STUDIES
2p-3p
BUS
BUS
BUS
BUS
BUS
3p-4p
WATCHED BY
15YO NEIGHBOR
WATCHED BY
15YO NEIGHBOR
WATCHED BY
15YO NEIGHBOR
WATCHED BY
15YO NEIGHBOR
WATCHED BY
15YO NEIGHBOR
4p-5p
WATCHED BY
15YO NEIGHBOR
WATCHED BY
15YO NEIGHBOR
CBT
WATCHED BY
15YO NEIGHBOR
WATCHED BY
15YO NEIGHBOR
5p-6p
WATCHED BY
15YO NEIGHBOR
WATCHED BY
15YO NEIGHBOR
DINNER OUT
WITH MOM
FAMILY
PSYCHOTHERAPY
WATCHED BY
15YO NEIGHBOR
6p-7p
WATCHED BY
15YO NEIGHBOR
7p-8p
WATCHED BY
15YO NEIGHBOR
8p-9p
9p-10p
10p-11p
27 hours of Therapy
16% of Adam’s week
30
4/16/2014
Fri
Sat
6a-7a
RESTORATIVE
SLEEP
MORNING
ROUTINE
MORNING
ROUTINE
MORNING
ROUTINE
MORNING
ROUTINE
MORNING
ROUTINE
RESTORATIVE
SLEEP
7a-8a
RESTORATIVE
SLEEP
Sun
BUS/NUTRITIOUS
Mon
BUS/NUTRITIOUS
BUS/NUTRITIOUS
BUS/NUTRITIOUS
BUS/NUTRITIOUS
BRKF & ART JOURNAL
BRKF & ART JOURNAL
BRKF & ART JOURNAL
BRKF & ART JOURNAL
BRKF & ART JOURNAL
MORNING
ROUTINE
8a-9a
MORNING
ROUTINE
SPEC ED
STUDIES
SPEC ED
STUDIES
STUDENT FARM
SPEC ED
STUDIES
SPEC ED
STUDIES
BREAKFAST
WITH MOM
9a-10a
BREAKFAST
WITH MOM
SPEC ED
STUDIES
SPEC ED
STUDIES
STUDENT FARM
SPEC ED
STUDIES
SPEC ED
STUDIES
4H AT
STUDENT FARM
10a-11a
SUNDAY SCHOOL
SOCIAL SKILLS
SPEC ED
STUDIES
SPEC ED
STUDIES
STUDENT FARM
SPEC ED
STUDIES
SPEC ED
STUDIES
4H AT
STUDENT FARM
11a-12n
SUNDAY SCHOOL
SOCIAL SKILLS
SPEC ED
STUDIES
SPEC ED
STUDIES
STUDENT FARM
SPEC ED
STUDIES
SPEC ED
STUDIES
4H AT
STUDENT FARM
12n-1p
SUNDAY SCHOOL
SOCIAL SKILLS
SPEC ED
STUDIES
SPEC ED
STUDIES
STUDENT FARM
SPEC ED
STUDIES
SPEC ED
STUDIES
4H AT
STUDENT FARM
1p-2p
OUTDOORS
SPEC ED
STUDIES
SPEC ED
STUDIES
T ECH T UTORING
SPEC ED
STUDIES
SPEC ED
STUDIES
BIG BROTHER
2p-3p
OUTDOORS
GRANDFATHER
PICK-UP
BOYS CLUB OF AM
FREE PLAY
BOYS CLUB OF AM
FREE PLAY
BOYS CLUB OF AM
FREE PLAY
BIG BROTHER
3p-4p
OUTDOORS
WITH
GRANDPARENTS
BCA
MARTIAL ARTS
BCA ART
“THERAPY”
WITH MOM
WITH MOM
WITH MOM
OUTDOORS
4p-5p
WITH MOM
DINNER WITH
GRANDPARENTS
Tue
Wed
TECH
TUTORING
HOMEWORK
WITH TUTOR
CBT
Thu
BCA
BCA
STAINED GLASS
MARTIAL ARTS READING SKILLS WORK W/MOM
BCA
BCA OBSTACLE STAINED GLASS
COURSE
WORK W/MOM
MUSIC JAM
5p-6p
DINNER WITH
WITH
PREP & DINNER
FRIENDS/FAMILY GRANDPARENTS
WITH MOM
DINNER OUT
WITH MOM
6p-7p
DINNER WITH
FRIENDS/FAMILY
GAMES W/MOM
& G-PARENTS
HOMEWORK
WITH MOM
ACTIVITIES
WITH MOM
PREP & DINNER
FAMILY
PSYCHOTHERAPY
WITH MOM
DINNER
WITH MOM
ACTIVITIES
WITH MOM
PREP & DINNER
WITH MOM
DINNER
WITH MOM
7p-8p
DOWN T IME
WITH MOM
HOMEWORK
WITH MOM
DOWN T IME
WITH MOM
ACTIVITIES
WITH MOM
HOMEWORK
WITH MOM
ACTIVITIES WITH
MOM
DOWN T IME
WITH MOM
8p-9p
MEDIA
CHOICE
MEDIA
CHOICE
MEDIA
CHOICE
MEDIA
CHOICE
MEDIA
CHOICE
MEDIA
CHOICE
MEDIA
CHOICE
9p-10p
DOWN T IME
ALONE
DOWN T IME
ALONE
DOWN T IME
ALONE
DOWN T IME
ALONE
DOWN T IME
ALONE
DOWN T IME
ALONE
DOWN T IME
ALONE
10p-11p
BEDTIME
ROUTINE
BEDTIME
ROUTINE
BEDTIME
ROUTINE
BEDTIME
ROUTINE
BEDTIME
ROUTINE
BEDTIME
ROUTINE
BEDTIME
ROUTINE
Adam now has
“MOBIUS THERAPY”
The NMT is being used to
guide and provide
Developmentally Appropriate
Therapy (DAT)
HIS THERAPY IS FLUID AND
CONTINUOUS, WITHOUT A START OR
END POINT TO THE DAY OR WEEK.
He is always being looked after by
an adult who understands and can
therapeutically support his
developmental needs.
31
4/16/2014
Möbius Care Models are Predictable but
Flexible, Neurobiologically Informed,
Developmentally Appropriate, and Dynamic.
The goal of MTP is not to adhere to a rigid therapeutic
schedule, but instead it is to promote a comprehensive
process of therapeutic planning, a thoughtful selection of
therapies and therapists, and a vision of therapy as
continuous and contextual. Daily routines may vary widely
from the plan. Tracking of the actual events of a day or week,
and comparing this to the original therapeutic plan can
provide the further advantage of analysis that identifies
rhythms and open opportunities for various therapeutic
modalities and ways to optimize therapist/child interactions.
TWO THINGS
Never stop.
24 x 7 = 168 hours week
Available now at:
American
Psychiatric Publishing
WWW.APPI.ORG/SEARCHCENTER/PAGES
/SEARCHDETAIL.ASPX?ITEMID=62455
OR AMAZON
HTTP://WWW.AMAZON.COM/INFANT-
EARLY-CHILDHOOD-MENTALHEALTH/DP/1585624551
32