Training in Complex Trauma for Value Behavioral Health Providers

I'm in Pittsburgh now, November 17, 2011. I'll be doing a presentation for Value Behavioral Health about evaluating and treatment Complex Trauma tomorrow. VBH manages the Medicaid contract for the State of PA for Western PA, so there will be about 350 providers at the training.

Dyadic Developmental Psychotherapy: Video on Attachment Focused Therapy

The Association for the Treatment and Training in the Attachment of Children has a wonderful new video about Attachment Focused Therapy. You can view it here. This video is a must see for parents and professionals. It describes the latest information on evidence-based, effective, and empirically validated treatments for Complex Trauma, Reactive Attachment Disorder, and other disorders of attachment. The speakers and presenters are internationally recognized experts in the evaluation and treatment of these conditions.

See the video here.

Theory of Mind and Attachment

Theory of Mind (ToM) can be defined as the ability to work out what other people are thinking and how this might affect their behavior. In most children ToM shows a significant advance between the ages of three and five. However, the development of ToM is severely delayed in children with autism. In addition, children who have experienced significant trauma and have disorders of attachment also show limited ToM. Several studies have shown that having brothers and sisters can improve children's ToM and researchers from the University of Queensland in Australia studied sixty children with autism to see if this was the case for them too. The researchers measured the children's ToM, executive functioning, verbal mental age and autism symptoms and compared this to the number of siblings the children had and where they fitted into the sequence. The researchers found that the children with older siblings actually had a weaker ToM, perhaps because their older brothers and sisters helped them to interpret other people's actions and stopped them from developing their own skills. Having younger siblings led to a weak improvement in ToM but this was not significant once mental age and autism symptoms were taken into account.

O'Brien, Karen, Slaughter, Virginia and Peterson, Candida C. - Sibling influences on theory of mind

development for children with ASD Journal of Child Psychology and Psychiatry
doi:10.1111/j.1469-7610.2011.02389.x

Effects of Institution care on adoptees

What happens when children from severely-deprived institutional backgrounds are adopted into caring families?

Many children adopted internationally have spend months or years in institutional settings. Orphanage care can, at best, be described as neglectful. There is often multiple caregivers and little consistency in care. The opportunity for a caregiver to develop a sensitive, attuned, and responsive relationship with the infant/child is limited or non-existent.

We are finding some answers to these questions bit by bit, as the English and Romanian Adoptees (ERA) Study continues to follow a group of over 300 children adopted from Romanian orphanages in the early 1990s. The ERA researchers are in the process of comparing the Romanian adoptees to non-adopted children as well as to adopted children who never had institutional care. This work is enormously time-consuming and complex, and involves repeated measurements and interviews at different ages, plus delays associated with analyzing, writing, and publishing the results of each phase of the investigation.

A recent presentation of the children’s characteristics up to age fifteen has been published by Michael Rutter and co-authors as "Deprivation-specific psycholcogical patterns: Effects of institutional deprivation" (Monographs of the Society for Research in Child Development, Serial No. 295, Vol.75, No. 1, 2010). The 252 pages of this monograph are absolutely packed with information.

An aspect of the monograph that will be of interest to many is the question raised in the title: whether there are psychological patterns that follow severe social and other deprivation in early life. The ERA investigated a group of characteristics that seemed more likely to occur in post-institutional children than in other adoptees. The following items were included:

1. Quasi-autism: A behavior pattern not identical with autism, but including rocking, self-injurious behavior like hair-pulling, unusual and exaggerated sensory responses, and tantrums in response to changes in routine, as reported in parent interviews (Gindis, B. [2008]. Institutional autism in children adopted internationally: Myth or reality? International Journal of Special Education, 23, 118-123).

2. Disinhibited attachment, as shown in unusual friendliness toward strangers and failure to show strong preferences for familiar people in threatening circumstance. The monograph describes disinhibited attachment as including “inappropriate approach to unfamiliar adults, a failure to check back with a caregiver in unfamiliar settings, and willingness to accompany a stranger and wander away from a familiar caregiver. It is often associated with a lack of appropriate physical boundaries, so that children may interact with strangers intrusively and even seek out physical contact… there is sometimes inappropriate affectionate behavior with strangers and undue physical closeness” ( Monograph, p. 58) .

3. Cognitive impairment, including problems with “mentalization” or the ability to understand what other people might believe or feel about a situation.

4. Inattention and overactivity similar to attention-hyperactivity disorders.

While by no means all children who had come from institutions displayed these problems, even those who had spent more than 6 months in a Romanian orphanage, the ERA group reported that over 90% of those who still showed the behaviors at age 15 had spent more than 6 months in severe deprivation. Those who persisted to age 15 with these problems had often improved (for example, become more likely to be helpful or comforting to others), but odd behaviors still occurred. Some children “annoyed other people but did not know why, and difficulties making or keeping friends were common… In a few cases, … inappropriate remarks included excessively outspoken sexualized use of language” ( Monograph, p. 86). Some children were reported as fascinated with collections, including those of “useless rubbish” like chocolate wrappers.

NEW BOOK

I have written a new book,
Dyadic Developmental Psychotherapy: Essential Practices & Methods
which is due out later this year. It is as close to a treatment manual as one can get with an experimentally based approach for this evidence-based, effective, and empirically validated treatment.

The book describes the theory base of Dyadic Developmental Psychotherapy and the evidence base of the approach. Another chapter describes fourteen components of Dyadic Developmental Psychotherapy. A major chapter in the book describes the phases of treatment:
Developing the Alliance
Maintaining the Alliance
Exploration
Integration
Healing
and the differential uses of the components of Dyadic Developmental Psychotherapy in these phases.
There are chapters about working with care-givers and the importance of caregivers as the key-stone for successful treatment

The book has extensive transcripts and excerpts from actual treatment sessions to illustrate the components and phases and principles being described.

Therapists, parents, psychologists, researchers, professors, social workers, residential treatment staff, and child welfare staff will all find this book a valuable resource.

Suicide and Child Abuse: a link

Suicide is one of the leading causes of death worldwide but what causes it is still not well understood. Mental-health problems are an important risk factor but most people with a mental-health problem do not think about killing themselves. There is strong evidence that people's experiences contribute more towards their mental-health problems than their genes and that bad experiences in people's childhood are linked to more thoughts about, or attempts at, killing oneself in later life. However, there has been less research into this than into genetic factors or mental-health problems. A team of researchers led by Ronny Bruffaerts from Gasthuisberg University Hospital in Belgium studied an international sample of 55,299 people asking them about their experiences in childhood and whether they had thought about, or tried to kill themselves. They found that bad experiences in childhood were associated with an increased risk of suicide attempts and thoughts of suicide. Sexual and physical abuse, especially during adolescence, were consistently the strongest risk factors.

Reference:
Bruffaerts, Ronny ... [et al] - Childhood adversities as risk factors for onset and persistence of suicidal behaviour. British Journal of Psychiatry, July 2010, 197(1), 20-27

Seel

Bipolar Disorder in Children: Is it being Over-diagnosed?

Is Bipolar Disorder being over-diagnosed in children?

Many people erroneously argue that it is, so let's take a look at the evidence. First, I am talking about children aged five years into adolescence who actually meet the full DSM-IV criteria for Bipolar Disorder. I am not discussing children who only have irritability or aggression without any other manic criteria.

FACTS:
In 1994/1995 the frequency of the Bipolar Diagnosis was 25 cases per 100,000. In 2002/03 the frequecny increaed over forty-fold to 1003 cases per 100,000. (See: National Trends in the Outpatient Diagnosis and Treatment of Bipolar Disorder in Youth, Carmen Moreno, MD; Gonzalo Laje, MD; Carlos Blanco, MD, PhD; Huiping Jiang, PhD; Andrew B. Schmidt, CSW; Mark Olfson, MD, MPH, Arch Gen Psychiatry. 2007;64(9):1032-1039.)

Put another way, the diagnosis of Bipolar Disorder rose from 0.01% in 1994 to 0.44% in 2002. That is certainly a 40X increase, but is it really over-diagnosis?

The standard method to estimate the actual prevalence of psychiatric conditions is to conduct an epidemiological study, where trained researchers study large representative samples of the general population (not preselected clinical samples) with standardized, validated instruments (like the SCID or MINI or CIDI) to assess and diagnose the general population using DSM-IV criteria (not just irritability or aggression in children as bipolar disorder, for instance). Using those methods in over 5000 persons, the most recent analysis (see: Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication
Ronald C. Kessler, PhD; Patricia Berglund, MBA; Olga Demler, MA, MS; Robert Jin, MA; Kathleen R. Merikangas, PhD; Ellen E. Walters, MS, Arch Gen Psychiatry. 2005;62:593-602.) reports a one year adult prevalence of bipolar disorder (types I and II) of 3.9%. In an analysis of age of onset in the same citation above, the study found that bipolar disorder began before adulthood in a substantial minority of persons: in 25% of persons, it began by age 17, in 10% it began by age 13.

Let's do the math now and see what results. Excluding the adolescents up to age 17, and using the lower range of the NCS data:
If 10% of bipolar disorder begins by age 13, and 3.9% of the total population is diagnosable with the condition using DSM-IV criteria in a community-based epidemiological study of actual prevalence, then how many children should that clinical study have diagnosed with bipolar disorder? 0.10 multiplied by 0.39 is 0.039, or 0.39%. If we round to 0.4%, then we have the actual prevalence of bipolar disorder in children. The vaunted 40-fold increase from near zero led to the diagnosis being made in 0.4% of children based on percentage of office visits.

0.39% is about the same as 0.44%, so the purported evidence for over-diagnosis seems underwhelming, to say the least.

Notes from ATTACh

The Association for the Treatment and Training in the Attachment of Children has achieved a number of major accomplishments recently. In addition to preparing and publishing a Therapeutic Parenting Manual, A Clinical Practice Manual, and a wonderful DVD, it wrote an influential letter to the DSM V committee advocating for the inclusion of a diagnosis of Developmental Trauma Disorder. This is exciting work. This international association, with members from across the US, Canada, Europe and Asia is quite influential. Parents and professionals should visit the website of Association for the Treatment and Training in the Attachment of Children.

The organization is now working on a number of projects that will benefit therapists and parents.

Stockholm Syndrome: what it is

In August 2009, when Jaycee Dugard, a woman kidnapped 18 years ago, was found, the media reported that she displayed symptoms of the psychological disorder known as Stockholm Syndrome, so named after a famous Swedish robbery in which hostages sympathized with their captors. Housed in a shed in her captor’s backyard, Dugard was repeatedly raped since she was eleven years old. But when investigators questioned her, Dugard reported that her captor was a “great person.”

Dugard’s case is only one of the many news stories that have received worldwide media attention. The public is fascinated by victims’ seemingly inexplicable positive responses after having suffered physical, emotional, and sexual abuse.

In her groundbreaking book, Loving to Survive: Sexual Terror, Men’s Violence, and Women’s Lives, Dr. Dee Graham, one of the earliest Stockholm Syndrome researchers, identified four characteristics that typify those suffering from the syndrome:

1. Perceived threat to survival, and belief that the captor is able to carry out the threat at any time.
2. A captor carries out a small act of kindness, and the captive perceives it as redemptive.
3. The captive is isolated for a significant amount of time, such that the victim can only see through the captor’s perspective.
4. Perceived impossibility of escape.

Shirley Julich, a professor at the Auckland University of Technology in New Zealand, focuses her research on child sexual abuse. In 2005, she wrote a comprehensive report analyzing interviews with 21 survivors of childhood sexual abuse. In her attempt to understand her interviewers’ initial reticence to report abuse, she turned to Graham’s research, concluding that Stockholm Syndrome was indeed a major culprit, in effect contradicting an earlier child sexual abuse study conducted by the Otago Women’s Health Survey.

Shirley Julich’s full report is available here.


To read a more in-depth description of Stockholm Syndrome symptoms, read Dr. Joseph Carver’s Mental Health Matters blog post .


To get a brief history of major news stories featuring victims suffering from Stockholm Syndrome, read this recent Time magazine article.

Overview of Proposed DSM-V Changes

OVERVIEW OF PROPOSED DSM-V CHANGES

There are no proposed changes to the diagnosis of Reactive Attachment Disorder. In addition, the proposals to add Developmental Trauma Disorder of Complex Trauma have been rejected, which is most unfortunate. Many children who have experienced chronic early maltreatment within a caregiving relationship exhibit a range of symptoms across several domains. Without a diagnostic category of Developmental Trauma Disorder that captures the range and depth of dysfunction, we are left giving children a basket of different diagnoses. This can lead to treating a range of symptoms and not the underlying causative factors.

There are substantial changes proposed for the Diagnostic and Statistical Manual of Mental Disorders.
The American Psychiatric Association (APA) has posted the draft of DSM-V on a special Web site, www.dsm5.org, to obtain comments.
A few of the proposed major changes:
• Recategorizing learning disorders, including creation of a single diagnostic category for autism and other socialization disorders, and replacing the controversial term "mental retardation" with "intellectual disability"
• Eliminating "substance abuse" and "substance dependence" as disorders, to be replaced with a single "addiction and related disorders" category
• Creating a "behavioral addictions" category that will include addictions to gambling but not to the Internet or sex
• Offering a new assessment tool for suicide risk
• Including a category of "risk syndromes" for psychosis and cognitive impairment, intended to capture mild versions of these conditions that do not always progress to full-blown psychotic disorders or dementia, but often do
• Adding a new disorder in children, "temper dysregulation with dysphoria," for persistent negative mood with bursts of rage
• Revising criteria for some eating disorders, including creation of a separate "binge eating disorder" distinct from bulimia
• Using "dimensional assessments" to account for severity of symptoms, especially those that appear in multiple diagnostic categories
The draft diagnostic criteria will then undergo two years of field testing. The final DSM-V is scheduled for release in May 2013, a year later than originally planned.
New Categories for Dyslexia, Autism
In the area of neurodevelopmental disorders, DSM-V will put dyslexia and dyscalculia -- reflecting disabilities of reading and mathematics, respectively -- into a new category of learning disabilities.
Autism, Asperger's syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified will make up the new "autism and related disorders" category.
The head of the APA's work group on substance-related disorders, Charles O'Brien, MD, PhD, of the University of Pennsylvania, told reporters on a press call that substance dependence and abuse had no basis in the research on addictions.
"We unanimously agreed that . . . there really isn't evidence for an intermediate stage [short of addiction] that is now known as abuse," he said. Instead, there will be substance use disorders for each of the major types of drugs that cause problems, such as alcohol.
He added that the term "dependence" was problematic as a psychiatric diagnosis because some types of physical dependence are "completely normal" for some medications, such as opioid painkillers. The draft, DSM-V will include "discontinuation syndromes" to allow for the proper assessment of symptoms of withdrawal from psychoactive substances, including caffeine.
Dimensional and Risk Assessments
There are two new suicide risk assessment scales planned for DSM-V, one for adolescents and one for adults. The new risk assessment tools focus on risk factors such as impulsive behavior, heavy drinking, and chronic severe pain and illness. In DSM-IV, suicidal ideation is treated as a symptom of major depression and certain other disorders.
Temper Dysregulation Disorder to be used in some cases instead of Bipolar Disorder
There is a proposed new diagnosis. The proposed new childhood disorder, temper dysregulation with dysphoria (TDD). It is reported that about 40% to 60% of the cases seen will be children who are doing things that other people don't want them to do. Many of these are children who are "stubborn and resistant and disobedient and moody, according to David Shaffer, MD, of Columbia University. There is currently a recognized syndrome known as oppositional defiant disorder, but some children also display severe aggression and negative moods that go beyond mere stubbornness.
Such children are often tagged as having juvenile bipolar disorder, but research has shown that the label is often inappropriate, since they usually do not qualify for a bipolar disorder diagnosis when they reach adulthood, although they remain dysfunctional. More often, these children are diagnosed as depressed when they become adults, according to Dr. Shaffer. He said the addition of TDD would better describe the severity and frequency of irritable behavior while also recognizing the mood disorder that goes with it.
Dimensional Assessment
Another innovation in DSM-V will be the extensive use of so-called dimensional assessments. Whereas DSM-IV relied heavily on present-absent symptom checklists, the new edition will include severity scales for symptoms, such as anxiety or insomnia, that may appear to larger or smaller degrees in many different mental illnesses.
Gender Identity Disorder Stays
A closely watched issue in the DSM-V revision has been whether to change or do away with gender identity disorder, now listed in DSM-IV. In the draft, APA leaders are proposing to rename the condition "gender incongruence" for adults and children.
People who consider themselves "transgendered" have long criticized DSM-IV and previous editions for labeling them with a mental disease when their problems, they believe, are purely somatic -- that is, they have the wrong genitalia and hormonal balance.
At the APA's annual meeting last May, members of the transgender community made a case for dropping gender identity disorder from DSM-V, but keeping some kind of "gender variance" diagnosis as a medical condition. Such an approach would eliminate the stigma of a psychiatric diagnosis while leaving a pathway for third-party payment for gender transition treatments, they said.
APA officials said the organization planned more discussions with members of the transgender community.
Kupfer, the DSM-V task force chairman, stressed that further changes in many diagnostic categories are likely following the comment period and field trials.
Final revisions will be submitted in 2012 for approval by the APA's two governing bodies, the Assembly and the board of trustees.

Treatment for PTSD

Post Traumatic Stress Disorder (PTSD) is quite different from Complex Trauma. PTSD is a clinical diagnosis usually applied when an person has experienced a life-threatening event and develops certain symptoms. Complex Trauma refers to the pervasive effects of chronic early maltreatment within a care-giving relationship. Complex Trauma usually results in more impairments that does PTSD.

Dyadic Developmental Psychotherapy is an evidence-based, effective, and empirically validated treatment for Complex Trauma.

Post-traumatic stress disorder (PTSD) is characterized by symptoms such as repeated, intrusive upsetting memories of the trauma; avoidance of similar situations and things which might remind one of them; a feeling of detachment from others; hypervigilance, and overarousal. It is associated with problems at work and at home and it is estimated that between 1% and 14% of people might suffer from it over the course of their lifetime. A team of researchers from New York reviewed 57 studies into treatments for PTSD and acute stress disorder which can often lead to it. They found that there was the strongest evidence for trauma-focused cognitive-behavioural therapy (CBT) and eye-movement desensitization and reprocessing (EMDR). There was some evidence that stress innoculation training, hypnotherapy, interpersonal psychotherapy and psychodynamic psychotherapy were effective for PTSD and that trauma-focused CBT was effective for acute stress disorder. The study also found evidence that trauma-focused CBT was effective for assault- and road-traffic-accident-related PTSD.

Ponniah, Kathryn and Hollon, Steven D. - Empirically supported psychological treatments for adult acute stress disorder and posttraumatic stress disorder: a review Depression and Anxiety December 2009, 26(12), 1086-1109

More on Nature and Nurture and Violence

In intriguing research conducted at the University of California and other locations, it appears that psychopathic killers often have lower intelligence, which can be the result of brain damage; often from severe chronic maltreatment as a child. Three factors appear to be present among violent offenders:
1. Several "violence" genes.
2. Damage to certain areas of the brain
3. Exposure to extreme trauma and poor parental bonding in childhood.

Among genetic markers related to aggression and mood is MAOA. The high risk variant of this gene gets inherited more by males than females. MAOA regulates serotonin, which affects mood (which is why medications like Prozac affect mood. These medications are called SSRIs: Selective Serotonin Reuptake Inhibitors. They function to keep more serotonin in the synapses between brain cells.). In the womb the high-risk version of MAOA can lead to a buildup of serotonin in the brain making the brain less sensitive to the normally calming effects of serotonin. Other research indicates that people who inherit the high-risk gene and who are raised in abusive homes may be more prone to violent behavior.

In another study pbulished in Comprehensive Psychiatry early in 2009, it was found that boys who inherit a mutated variant of MAOA are more likely to be in a gang than those without the mutation and are more likely than those without the mutation to be the most violent gang members.

Master Class in Dyadic Developmental Psychotherapy

A new Master Class for Therapists is planned for 2010.
This class is designed to teach therapists how to provide Dyadic Developmental Psychotherapy, which is an evidence-based, effective, and empirically validated treatment.

MASTER CLASS

Dyadic Developmental Therapy
(An attachment-based therapy)

Training for Therapists in the Treatment of Children with Trauma-Attachment Problems

2010

This workshop is for professionals who have a working knowledge of attachment, how it develops, how attachment disorders develop, and a general knowledge of treatment principals and attachment theory.

Early deprivation, neglect, abuse, significant early health problems and hospitalizations, repeated moves, or more than one year in an orphanage can create attachment problems that require specialized treatment. Traditional forms of therapy are ineffective with attachment-disordered children. This workshop will provide the therapist and other professionals with an opportunity to learn and practice effective treatment methods for trauma-attachment disordered children.

Participants are encouraged to bring in videotapes of sessions or to make arrangements to have a family attend a session for a consultation with the therapist and Dr. Becker-Weidman. .

Dyadic Developmental Psychotherapy is an evidence-based treatment, effective, and empirically validated treatment that is grounded in current thinking and research on the etiology and treatment of Complex Trauma or Developmental Trauma Disorder. Treatment had an educational dimension, designed to help parents understand their child’s attachment disorder: how the child feels and thinks, and the child’s internal psychological dynamics. Second, teaching parents about attachment-facilitating parenting methods and the importance of attunement and responsive, sensitive parenting is essential. Direct work with the parents regarding their own family or origin issues is another componen5t of treatment. Finally, intensive emotional work with the child in a manner consistent with sound treatment principles is vital.

The workshop is led by Dr. Arthur Becker-Weidman, who is certified by the Dyadic Developmental Psychotherapy Institute as a certified Dyadic Developmental Psychotherapist, Certified Consultant, and Certified Trainer. This workshop provides training hours that may be used by the participant to meet the required training hours necessary to become a Certified Dyadic Developmental Psychotherapist.

Purpose of Workshop

This workshop is for therapists who want to learn how to treat trauma-attachment disordered children. Participants will learn effective therapy principals for helping traumatized children. Participants will learn:

Initial assessment and treatment planning.

Beginning, middle, and ending phase interventions.

Developing attunement and maintaining attunement.

Practical implications of the relationship between neurobiology and attachment.

Effective therapeutic techniques to use with traumatized and attachment disordered children.

Effective parenting principals.

Participants will have the opportunity to view videotapes of actual therapy sessions with traumatized children that demonstrate therapeutic principals, present their own video tapes or bring in a client for a consultation, and view live therapy sessions.

SCHEDULE

A Six-month 42-hour Master Class.
10:00 am – 5:00 pm, March 27 – August 28, 2010 (3/27, 4/24, 5/22, 6/26, 7/24, 8/28). The schedule may be adjusted if all the participants agree, so contact the office for the most current schedule. Limited to 7 professionals.

OUTLINE

Evaluation & parenting preparation.
First session, beginnings, attunement, and managing resistance.
Neurobiology of interpersonal experience
Middle phase issues & psychodrama
Facilitating parent-child attachment
Complex Post Traumatic Stress Disorder.
Ending phase issues.

The treatment presented has demonstrated effectiveness. A follow-up study (see our website) clinically and statistically significant reductions in symptoms of attachment disorder, aggression, anti-social behavior, thought disorders, attention problems, mood, and social relationship dysfunction. Over 80% of the children treated had previously been in treatment on three or more occasions, without any noticeable improvement. Dyadic Developmental Psychotherapy produced measurable and stable improvements. Treatment averaged 23 sessions over approximately ten months. (Arthur Becker-Weidman, Ph.D., Child & Adolescent Social Work, vol. 23, pp.137-171, 2006)

Click here for the brochure. http://www.center4familydevelop.com/2010MasterClass.pdf

What I've learned by working overseas

Recently a psychologist from the Czech Republic completed a month-long training program at The Center for Family Development. I’ve been reflecting on how training professionals from other countries here at the Center, and my travels training others overseas has affected my work I’ve trained professionals from any countries: Canada, Singapore, Australia, Bermuda, Finland, and the Czech Republic. Those of you who teach may have an experience similar to mine; that teaching keeps my thinking fresh, current, and in an ongoing process of development. Having to explain and demonstrate treatment principles causes me to think about my work and the work of others in a fresh and deep way. It also prods me to read and research. Training professionals from other nations who have a different culture, history, and language has enriched my work in a number of ways. It causes me to think about the differences in:
Child Welfare policies
Child Welfare practices
Effects of different experiences on child development
Universals
The meaning of symptoms
The meaning of words

Some examples of the differences I’ve noticed in child welfare policy and practice include the following. In the US many domestically adopted children receive a subsidy from the state. This is to encourage families to adopt since adoption is preferable to “permanent” foster care. Many other nations do not provide adoption subsidies and we find that their placement rates are much lower than in the US and the length of time children spend in care is much longer. The Czech Republic uses primarily institutional care for children and not foster care. In some countries the government places children only within their community (ethnic and religious).

My travels and training at the Center have led me to think much more precisely about language. For example, some concepts and words in our language are very difficult to translate into the other language, For example, the concept “Dyadic” in Dyadic Developmental Psychotherapy cannot be translated into Finnish. I think much more precisely about language in my practice and I listen carefully to words and the many meanings of similar words. Words define and give meaning to experiences and define one’s reality. Different words lead to different meanings and different realities, even though the objective experiences may be the same in treatment now I focus a lot on the words families and children us and how that affects relationships for good and bad. For example, how often have you heard a child say, “I was bad,” instead of “I did something bad/wrong.” What a difference that represents. Or, “When I think about John and my kids,” versus “When I think about John and my other sons.” My work overseas as made me more open to ambiguity in language and to then explore that ambiguity (“What do you mean by xxxx,” or “Does that mean xxxx?”). I find that clarifying those ambiguities is helpful for development and healing. Discussing the meaning of events, experiences, and words with families and helping them discuss that among themselves seems to help increase their reflective function, empathy, and insightfulness.

Future hope for eliminating Trauma Memories

In exciting new developments, researchers at SUNY Downstate Medical Center in Brooklyn, NY have shown that they could erase memories using a single substance in a single does. This may lead to being able to eliminate traumatic memories and the effects of Complex Trauma and PTSD. The substance appears to block the activity of a substance that the brain needs to retain information and memories. While the practical applications of this new research to humans in years or decades away, it shows the great advances that research into brain functioning are beginning to yield practical results.

Dyadic Developmetal Psychotherapy receives support

The new book, Treating Complex Traumatic Stress Disorder, edited by Christine Courtois and Julian Ford, The Guilford Press, NY, 2009, supports the various elements, principles, and techniques of Dyadic Developmental Psychotherapy. The chapter on family therapy approaches states, "Meta-analytic studies have found family based treatments to be more effective than treatment as usual (TAU)...The strongest evidence for the efficacy of family therapy for traumatic stress disorders is provided by studies with families of traumatized toddlers and preschool- or early elementary school-aged children." pp394-395.

The book describes the importance of affect regulation, focusing on attachment relationships in treatment, attention to developmental level and processes, emotional regulation, titrated exposure to traumatic memories, therapeutic alliance, intersubjectivity, and other topics that are core principles and methods of Dyadic Developmental Psychotherapy. It is heartening to find additional support for the use of DDP in the treatment of attachment and trauma disorders.

The book describes practice principles for treating children with complex traumatic stress disorder which are quite consistent with previous material published about DDP over the last several years:
1. Safety First
2. A relational bridge must be developed to engage, retain, and maximally benefit the child and caregiver(s).
3. Diagnosis, treatment planning, and outcome monitoring are always relational.
4. Diagnosis, treatment planning, and outcome monitoring are always strengths-based.
5. All phases of treatment should aim to enhance self-regulation competencies.
5a. Emotional regulation.
5b. Attention, memory, decision making (information processing).
5c. Self-regulation of consciousness and motivation.
5d. Bodily self-regulation.
5e. Relational self-regulation.
6. Determining with whom, when, and how to address traumatic memories.
7. Preventing and managing relational discontinuities and psychosocial crises.
from pages 67-78.
As described and elaborated in the book, these principles have also been previously described and elaborated on in various publications about DDP (several books and journal articles).

New Research on Developmental Functioning

We have completed a study that is due to be published soon that shows that children with Reactive Attachment Disorder and Complex Trauma function at a much younger age than their chronological age. The study used the Vineland Adaptive Scales -II and found that the children in the study had a developmental age notably lower than their chronological age. In addition, we found that their receptive communication score was significantly lower than their expressive communication score, suggesting that at times the child's not "listening" may be caused by the child not understanding what the child was asked, rather than being non-compliance or defiance. There are a number of other important findings for this study, which is the first of it's kind to explore the developmental functioning of this group of children.

The article describes several important implications for clinical practice, parenting, child welfare practice, education, and further research.

I will post additional information about this study in later posts and as soon as the article is published, I will provide a link to it.