Patricia Mares , M.Ed., PC, LSW controlrad / 740-703-5048 Alvin Mares, PhD, LSW

1. In-Home SFBT for Troubled Youth9th Annual (2011) Conference of the SFBTA Bakersfield, CA Workshop Session 1d, 10:45a-noon Friday, November 11th, 2011 Patricia Mares, M.Ed., PC, LSW www.controlrad.com/ 740-703-5048 Alvin Mares, PhD, LSW mares.2@osu.edu / 740-804-6275

2. PTSD • Definition • Severe anxiety disorder that can develop after exposure to any event that results in psychological trauma • Symptoms • Re-experiencing original trauma(s) through flashbacks or nightmares, avoidance of stimuli associated with the trauma, and increased arousal – such as difficulty falling or staying asleep, anger, and hypervigilance • Formal diagnostic criteria (both DSM-IV-TR and ICD-10) require symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning

3. PTSD (con’t) • Prevalence (adults) • 4% general population • 12-13% Iraq war vets; 15% among Vietnam War vets; • 25% among those placed into foster care (ages 14-18) • Risk factors • Childhood trauma, chronic adversity, and familial stressors increase risk for PTSD Symptoms • Effect of childhood trauma may be marker for both traumatic experiences and attachment problems Source: Wikipedia • http://en.wikipedia.org/wiki/Posttraumatic_stress_disorder

4. Reactive Attachment Disorder (RAD) • Characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts • Arises from failure to form normal attachments to primary caregivers in early childhood resulting from… • severe early experiences of neglect, abuse, abrupt separation from caregivers between ages 6 mos. & 3 yrs. • frequent change of caregivers • lack of caregiver response to child's communicative efforts • Example: Infants & toddlers growing up in orphanages in Eastern Europe in very deprived conditions

5. RAD (con’t) • Two forms • “Inhibited”: persistent failure to initiate or respond most social interactions in developmentally appropriate way • Extreme reluctance to initiate or accept comfort and affection, even from familiar adults, especially when distressed • “Disinhibited”: indiscriminate sociability, such as excessive familiarity with relative strangers • Indiscriminate and excessive attempts to receive comfort and affection from any available adult or peer, even relative strangers • Grossly disturbed internal working models of relationships often leading to interpersonal and behavioral difficulties in later life

6. RAD (con’t) • Diagnostic criteria: • Markedly disturbed and developmentally inappropriate social relatedness in most contexts; • Disturbance not accounted for solely by developmental delay and does not meet the criteria for pervasive developmental disorder • Onset before five years of age • History of significant neglect • Lack of identifiable, preferred attachment figure • Source: Wikipedia • http://en.wikipedia.org/wiki/Reactive_attachment_disorder

7. RAD & Troubled Youth Behaviors • Overly cute, charms others to get them to do what he/she wants. • Trouble making eye contact when adults want him/her to. • Overly friendly with strangers. • Pushes caregiver away or becomes stiff when tries to hug him/her. • Argues for long periods of time, often about ridiculous things. • Tremendous need to have control over everything. • Acts amazingly innocent when caught doing something wrong. • Does very dangerous things, ignoring danger. • Deliberately breaks or ruins things. • Lacks conscience for his/her actions. • Teases, hurts, or is cruel to other children. • Unable to stop him/herself from doing things impulsively. • Steals • Demands things, instead of asking for them.

8. RAD & Troubled Youth Behaviors • Doesn't learn from his/her mistakes and misbehavior. • Tries to get sympathy from others by claiming abuse/neglect. • “Shakes off" pain when he/she is hurt, refusing to accept comfort. • Sneaks things without permission. • Pathological liar • Very bossy with other children and adults. • Hoards or sneaks food • Can't keep friends for more than a week. • Throws temper tantrums lasting two hours or longer. • Chatters non-stop, asks repeated questions, mutters, etc. • Accident-prone, or complains about every little ache and pain. • Teases, hurts, or is cruel to animals. • Doesn't do as well in school as could with even a little more effort. • Sets fires, or is preoccupied with fire. • Prefers to watch violent cartoons and/or tv shows or horror movies.

9. Overview of 3 cases • 6 year old male, several incidents of arson; lived with paternal grandfather after being abandoned by mother and father • 7 year old male, tried to kill older brother; lived with single mom and older and younger brothers before being placed in foster care, returned home and back in care • 10 year old male, sexually and physically abused and abandoned by mother; multiple placements outside the home and now in residential treatment

10. CONTROL • Control: Adult must maintain it in order to gain trust. • Options: Youth provided with 2-3 options/alternatives acceptable to the caregiver • Neutrality: Caregiver uses neutral words and tone in response to “acting-out” behavior to demonstrate continued control over youth and situation. • Trust: Caregiver regularly provides youth with basic needs and psychological needs to cultivate feeling of trust and security. • Repetition: Caregiver repeats 3 times in simple language and neutral tone the natural consequence if “acting-out” behavior continues. • Others: Caregiver discusses with helping professional youth’s behavior and CONTROL principles being used to encourage positive behavior • Love: Caregiver shows empathy and care through use of customary hugs etc. ordinarily provided by parents; youth taught to understand difference between love and pity, and love themselves.

11. Evaluation Data • Youth & Caregiver Characteristics (at BL) • Demographic data • Clinical Contacts (for each “session”) • RADIS Contact Form • Frequency, type & duration • CONTROL principle(s) discussed, with comments • SFBT principle(s) discussed, with comments • Problem; miracle; exception; scaling; compliment; homework; what’s better?; coping • Youth Outcomes (at BL & 6-mo FU’s) • RADQ symptoms • CBCL/6-18 behaviors • Ohio University IRB Protocol, “Reactive Attachment Disorder Intervention Study (RADIS)”; 7/11-6/15 (4 yrs) • Project website: www.controlrad.com

12. Case #1 • 5 year old female living with maternal grandmother because of birth mother’s AOD issues • child was unattached to mother and fighting attachment to grandmother • Grandmother required education and skills to deal with child calmly and consistently • In 4 meetings, grandmother had confidence to control child’s behaviors and went from a 2 to 7/8 on scaling

13. Case #2 • Clients are 17 year old fraternal twins, one female and one male and 14 year old boy all adopted into a two parent home • After 6 sessions, parents still frustrated and unable to apply neutrality • Ongoing work to use exception questions and coping strategies to support

14. Case #3 • 9 year old male, previously placed in foster care because of substantiated abuse by birth mom • After completing case plan and regaining custody, case was referred for aftercare • Birth mom had mother and sister involved in learning CONTROL methods • Work has been done with the school to educate about best techniques to deal with child