921: REACTIVE ATTACHMENT DISORDER: PARENTING AND THERAPEUTIC INTERVENTIONS A Training Outline Developed by: H. Elizabeth Coyle For: The Pennsylvania Child Welfare Resource Center University of Pittsburgh, School of Social Work June 2013 The Pennsylvania Child Welfare Resource Center University of Pittsburgh, School of Social Work 403 East Winding Hill Road Mechanicsburg, PA 17055 Phone (717) 795-9048 Fax (717) 795-8013 www.pacwrc.pitt.edu
Copyright 2013, The University of Pittsburgh This material is copyrighted by The University of Pittsburgh. It may be used freely for training and other educational purposes by public child welfare agencies and other notfor-profit child welfare agencies that properly attribute all material use to The University of Pittsburgh. No sale, use for training for fees or any other commercial use of this material in whole or in part is permitted without the express written permission of The Pennsylvania Child Welfare Resource Center of the School of Social Work at The University of Pittsburgh. Please contact the Resource Center at (717) 795-9048 for further information or permissions.
Agenda for the 3 Hour Workshop on Reactive Attachment Disorder: Parenting and Therapeutic Interventions Day One Estimated Time
Content
Pages
20 minutes
Section I: Welcome and Introductions
1-3
30 minutes
Section II: Definition and Characteristics of RAD and Related Disorders
4-5
45 minutes
Section III: Parenting Approaches to Facilitate Attachment
6-9
30 minutes
Section IV: Prevention and Intervention Parenting Strategies
11-12
35 minutes
Section V: Collaboration Techniques to Create a Team Approach
13-17
20 minutes
Section VI: Closing and Evaluations
18-20
921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions Section I: Welcome and Introductions Estimated Length of Time: 20 minutes Learning/Performance Objectives: 9 Identify and list learning needs for the training Method of Presentation: Lecture, small and large group discussion, large group activity Materials Needed: 9 Flip Chart Pads 9 Flip Chart Stands 9 Laptop 9 LCD Projector/Screen 9 Markers 9 Masking Tape/Poster Putty 9 Name Tents 9 Trainer-Prepared Flip Chart: What’s In It For Me? 9 Trainer-Prepared Flip Chart: Parking Lot 9 Handout #1: Agenda/Idea Catcher 9 Handout #2: Learning Objectives 9 Handout #3: RAD: Parenting and Therapeutic Interventions PowerPoint 9 Poster 1: Beliefs: About Self and World 9 Poster 2: Characteristics of Children with RAD and Related Disorders 9 Poster 3. Attachment Parenting Principles 9 PowerPoint Presentation: o Slide #1: RAD: Parenting and Therapeutic Interventions o Slide #2: Welcome o Slide #3: What’s In It for Me o Slide #4: Learning Objectives o Slide #5: Agenda
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions Section I: Welcome and Introductions Step 1: (10 minutes) Before participants arrive, display PowerPoint Slide #1: RAD: Parenting and Therapeutic Interventions, which is the introductory slide for the training. Whenever possible, start the training session promptly at 9:00 AM. Display PowerPoint Slide #2: Welcome. As participants arrive, welcome them and ask them to complete their name tents following the format below: • • • • •
Name (Center) County (Top-Right Corner) Number of Children (Top-Left Corner) Number of Years as a Resource/Adoptive Parent (Bottom-Left Corner) One thing they want to know about the topic (Bottom-Right Corner)
When the name and four corners are complete, ask participants to place their name tent in front of them. After all participants have arrived and completed their names tents, introduce yourself including your name, area of expertise, current position, years of experience and any other information related to the content. Ask the participants to introduce themselves to the large group using the information they have written on their name tents. Display PowerPoint Slide #3: What’s In It For Me. As the participants share the one thing that they want to learn about topic, write these thoughts on the What’s In It For Me? (WIIFM) flip chart. Tell participants that, at the end of the training, they will review the WIIFM flip chart to ensure that all of the concepts/questions have been addressed. Create a Parking Lot for those items that will not be addressed/are not addressed in the training. Explain to participants that the items posted on the Parking Lot are items that may not be addressed in this training; however, you will direct them to resources that can meet their needs. Step 2: (5 minutes) Discuss the following training room guidelines: • • •
The 15-Minute Rule Training Schedule – 9:00 to 12:00 with Breaks Document your Presence Via the Sign-In Sheet
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions • • • • •
Provide Constructive and Motivational Feedback Show Respect Take Risks Practice Makes Permanent Focus on Learning – Cell phones on vibrate
Step 3: (5 minutes) Trainer Note: The Agenda and Idea Catcher have been combined on one handout to help participants immediately capture interesting concepts that arise when you train a given section. Refer participants to their workshop packets and review the learning objectives and agenda for the workshop using PowerPoint Slide #4 (Learning Objectives), PowerPoint Slide #5 (Agenda), Handout #1 (Agenda/Idea Catcher) and Handout #2 (Learning Objectives). Note that participants can follow the slides on the screen using Handout #3 (RAD: Parenting and Therapeutic Interventions PowerPoint). Note Poster #1 (Beliefs: About Self and World), Poster #2 (Characteristics of Children with RAD and Related Disorders), and Poster #3 (Attachment Parenting Principles) hanging in the room that will be used throughout the training. Having given participants an overview of the content, it is now time to move into the next section of the training.
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions Section II: Definition and Characteristics of RAD and Related Disorders Estimated Length of Time: 30 minutes Learning/Performance Objectives: 9 Define symptoms of RAD 9 Describe the behaviors exhibited by children diagnosed with RAD 9 List the risk factors for development of RAD Method of Presentation: Lecture and large group discussion Materials Needed: 9 Flip Chart Pads 9 Flip Chart Stands 9 Laptop 9 LCD Projector/Screen 9 Markers 9 Masking Tape/Poster Putty 9 Poster #2: Characteristics of RAD and Related Disorders 9 Poster #3: Beliefs: About Self and World 9 Handout #1: Agenda/Idea Catcher (revisited) 9 Handout #4: Definitions and Characteristics of RAD and Related Disorders 9 PowerPoint Presentation: o Slide #6: Definitions and Characteristics of RAD and Related Disorders o Slides #7-8: Definition of RAD and Related Disorders o Slide #9-11: Characteristics of RAD and Related Disorders o Slide #12: Risk Factors
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions Section II: Definition and Characteristics of RAD and Related Disorders Step 1: Definition of RAD and Related Disorders, Description of Behaviors and Risk Factors (30 Minutes) Distribute Handout #4 (Definitions and Characteristics of RAD and Related Disorders). Display PowerPoint Slide #6 (Definitions and Characteristics of RAD and Related Disorders) and explain that this section of the training will cover the symptoms of RAD, describe the behaviors exhibited by children diagnosed with RAD, and the risk factors for development of RAD. Display PowerPoint Slides #7 & 8 (Definition of RAD and Related Disorders) and review definitions of RAD and related disorders. Display PowerPoint Slides #9, 10 & 11 (Characteristics of RAD and Related Disorders). Ask participants for examples of behaviors exhibited by children in their care that are described on each slide. These characteristics are also on Poster #2 (Characteristics of RAD and Related Disorders). Remind participants that more detailed information about the symptoms of RAD and related disorders are located on Handout #4 (Definitions and Characteristics of RAD and Related Disorders). Refer to Poster #1 (Beliefs: About Self and World) and emphasize that these beliefs held by children with RAD underlie the behaviors exhibited by the children. Their beliefs of self and the world explain their interactions with adults and peers, and why they operate out of a fear reaction. Display and review PowerPoint Slide #12 (Risk Factors) and note that these risk factors can set the stage for disordered attachment, particularly in the first two years of life. Note that some children who experience these risk factors are resilient and never develop a disorder or display the characteristics of children with RAD or related disorders. Ask participants to use Handout #1 (Agenda/Idea Catcher) to capture key learning points from this section of the training. Ask participants to share what they wrote on the handout.
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions Section III: Parenting Approaches to Facilitate Attachment Estimated Length of Time: 45 minutes Learning/Performance Objectives: 9 Describe parenting approaches that facilitate attachment 9 Identify parenting approaches already used and approaches that will be challenging to implement Method of Presentation: Lecture, small and large group discussion Materials Needed: 9 Flip Chart Pads 9 Flip Chart Stands 9 Laptop 9 LCD Projector/Screen 9 Markers 9 Masking Tape/Poster Putty 9 Poster #1: Beliefs: About Self and World 9 Poster #3: Attachment Parenting Principles 9 Handout #1: Agenda/Idea Catcher (revisited) 9 Handout #5: Attachment Parenting Approaches 9 PowerPoint Presentation: o Slide #13: Parenting Approaches to Facilitate Attachment o Slide #14: Attachment Parenting Approaches o Slide #15: Attachment Parenting Approaches: Questions for Reflection 9 Trainer Resources: Thomas, N. (1997). When Love Is Not Enough: A Guide to Parenting Children with RAD. Glenwood Springs, CO: Families by Design.
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions Section III: Parenting Approaches to Facilitate Attachment Step 1: Attachment Parenting Approaches (30 Minutes) Display PowerPoint Slide #13 (Parenting Approaches to Facilitate Attachment) and explain to participants that this section of the training will help them examine the parenting approaches they already use and offer additional ideas that are specifically aligned with the needs of children with disordered attachment. Display PowerPoint Slide #14 (Attachment Parenting Approaches) and distribute Handout #5 (Attachment Parenting Approaches). Quickly review the seven approaches of attachment parenting displayed on PowerPoint Slide #14 (Attachment Parenting Approaches) and explain that these seven approaches will be described in detail. Note that Poster #3 (Attachment Parenting Approaches) is available for reference throughout this section of the training. Ask participants to follow along using Handout #5 (Attachment Parenting Approaches) when each approach is explained. Take Care of Self First: Emphasize the critical importance of taking care of self because the behaviors exhibited by children with RAD and related disorders can be particularly draining for parents. These children need constant supervision and an abundance of nurturing which can quickly deplete the reserves of parents. Explain that a lock/alarm on the child’s bedroom door is used for the safety of children who leave their room during the night, posing a safety threat. Locks/alarms should be used only after discussion with the child’s caseworker and/or therapist and agreement that it is needed is obtained. Because children diagnosed with RAD have complex needs, a network of support must be created for the child as well as for the families to facilitate healing. Resource/adoptive parents play a central role in this team approach, along with the caseworker, birth parents, mental health professionals, medical personnel, ancillary therapists, and educators. More detailed information on collaborating in a team approach will be covered later in the training. Engender Respect: Resource/adoptive parents can’t engender respect in any realm of parenting without fully understanding the cultural background of the child. One example of this revolves around expectations for eye contact from the child when providing a directive. Note that eye contact should be expected only if culturally appropriate for the child. Explain to participants that more information on cultural competence will be shared later in the training. Explain that making direct eye contact when a directive is given may also be very difficult for children exhibiting frozen watchfulness. Parents should “read” the child’s The Pennsylvania Child Welfare Resource Center
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions body language feedback (tensing body as a signal) to determine how much distance to leave between the child/parent when giving a directive. Ask participants to provide an example of a “short” directive and how they would repeat it if the child doesn’t comply after stating the directive. Make sure the examples represent the approach of using as few words as possible to prevent auditory processing overload. Ask participants to give examples of developmentally appropriate games to play that practice compliance and respect. For example, Simon Says is a game that would be enjoyed by preschool-age children while freeze tag would be a game to play with school-age children. Create Structure and Consistency: Ask participants to provide examples of rules and routines they use in their household. Suggest that they display rules and routines in written or picture form to help the child remember the rules and follow the sequence of routines in the morning and at bedtime. Emphasize the need for consistency in all settings of the child’s life. Ask participants to identify one chore that the child could do successfully. Make sure examples are developmentally appropriate and set the child up for success. Explain that the chore should be taught explicitly and that the parent provides specific reinforcement when the child is successful (“You put the spoons on the dinner table right next to each person’s plate.”) Step 2: Attachment Parenting Approaches (continued) (30 Minutes) Establish Consequences and Restitution: Ask participants to provide examples of consequences for specific behaviors (natural or logical). If a child knocks over a sibling’s tower of blocks, rebuilding the tower with the sibling would be an appropriate consequence. Provide Nurture: Ask participants to provide examples of how they provide nurturance throughout the day and at bedtime. Emphasize the importance of following the child’s lead and response and moving slowly, particularly when the child first arrives in the home. Remind parents that these are the things that many of these children never received from their caregivers at critical stages of development when healthy attachment is forming. Process Feelings: Provide an example of how to reflect what a child is expressing (“Your face looks sad to me right now.” or “I would be angry too if that happened to me.”). Ask participants to identify how they help children process their feelings through pictures or words. Emphasize the use of time in versus time out and explain that time out only reinforces the child’s belief about self and the world. Refer to Poster #1 (Beliefs: About Self and World). Provide Child with Success: Ask participants to provide examples of a time their child successfully completed a task or directive and the words they used to reinforce the success. Make sure the words used to reinforce are specific and not a broad statement The Pennsylvania Child Welfare Resource Center
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions like “Good job.” Remind participants that many of these children are developmentally delayed and that expectations should be adjusted accordingly to facilitate success. Offer help when needed and supervise the task to be completed to increase the likelihood of success. Step 3: Identify Parenting Approaches that Are Already Used and Approaches that Are Challenging (15 minutes) Display PowerPoint Slide #15 (Attachment Parenting Approaches: Questions for Reflection). Ask participants to move into pairs and refer to HO#5 (Attachment Parenting Approaches). Guide them through the following steps: 1. Star the parenting approaches that you already use. 2. Place a check mark next to at least one parenting approach that you would like to start using. 3. Share with your partner the biggest challenge(s) you might face when trying out the new approach(es) and discuss why it might be difficult for you.
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions Step 4: Identify Parenting Approaches that Are Already Used and Challenging (continued) (15 minutes) After participants complete the partner activity, ask some of the parents to share their responses with the group. Identify any similarities in responses and explain why that might be so. Emphasize that each child needs specific parenting approaches that fit his/her unique needs. The “one size fits all” approach doesn’t work, especially for children diagnosed with RAD. Trainer Note: An alternative delivery method for Section III would be to ask participants to use Handout #5 (Attachment Parenting Approaches), and to star and check mark the approaches. Then proceed to begin the partner activity described in Step 3 above. Ask participants to use Handout #1 (Agenda/Idea Catcher) to capture key learning points from this section of the training. Ask participants to share what they wrote on the handout. (Note: This might be a good time in the training to give a 15 minute break.)
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions Section IV: Prevention and Intervention Parenting Strategies Estimated Length of Time: 30 minutes Learning/Performance Objectives: 9 Identify parenting strategies to prevent and manage the behaviors exhibited by children diagnosed with RAD 9 Apply parenting strategies through case vignette analysis Method of Presentation: Lecture, small and large group discussion, application through case vignette Materials Needed: 9 Flip Chart Pads 9 Flip Chart Stands 9 Laptop 9 LCD Projector/Screen 9 Markers 9 Masking Tape/Poster Putty 9 Poster #1: Beliefs: About Self and World 9 Poster #2: Characteristics of Children with RAD and Related Disorders 9 Handout #1: Agenda/Idea Catcher (revisited) 9 Handout #5: Attachment Parenting Approaches (revisited) 9 Handout #6: Parenting Strategies 9 PowerPoint Presentation: o Slide #16: Prevention and Intervention Parenting Strategies o Slide #17: Parenting Strategies o Slide #18: Parenting Strategies Practice: Case Vignette 9 Trainer Resource: Thomas, N. (1997). When Love Is Not Enough: A Guide to Parenting Children with RAD. Glenwood Springs, CO: Families by Design.
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions Section IV: Prevention and Intervention Parenting Strategies Step 1: Prevention and Intervention Parenting Strategies (30 Minutes) Display PowerPoint #16 (Prevention and Intervention Parenting Strategies) and explain that this section of the training provides information on prevention and management strategies to use in response to the behaviors exhibited by children diagnosed with RAD. Display PowerPoint Slides #17 (Parenting Strategies) and distribute Handout #6 (Parenting Strategies) for participants to use to review each strategy. Ask participants to share their reactions to the strategies listed. Respond to concerns about using these strategies, particularly if other children are in the home. How will they limit the amount of toys when other children are in the home? How difficult will it be to only provide the basics in the child’s room when other siblings’ rooms have more than the basics? Explain the rationale behind the Lego Level strategy to address concerns. Children with RAD are overstimulated easily. A “simple” environment helps them relax their alarm reactions and reduce sensory overload. These strategies are also preventative. When a child with RAD is experiencing a meltdown, they often will try to destroy toys and/or everything in their room. Explain that asking children with RAD why they lied or stole only gives them an opportunity to lie again by denying they did it or by accusing someone else of stealing the object. Refer to Poster #2 (Characteristics of Children with RAD and Related Disorders) and note that connecting behavior with a consequence and showing remorse are two developmental skills that will come with time. Mental health treatment and consistent parenting responses are critical to remediate the developmental delays. Note that the beliefs of the child listed on Poster #1 (Beliefs: About Self and World) set the stage for fear and denial as a means of survival and self-preservation. Display and review PowerPoint Slide #18 (Parenting Strategies Practice: Case Vignette). Ask participants to refer to Handout # 6 (Parenting Strategies), move into small groups, and identify the “short and sweet” steps they would take to address Terrance’s behavior described in the case vignette. Ask participants to share their responses with the large group. Refer to the Consequences and Restitution section on Handout #5 (Attachment Parenting Approaches) and discuss an appropriate consequence for Terrance’s lying and breaking curfew. Ask participants to use Handout #1 (Agenda/Idea Catcher) to capture key learning points from this section of the training. Ask participants to share what they wrote on the handout.
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions Section V: Collaboration Techniques to Create a Team Approach Estimated Length of Time: 35 minutes Learning/Performance Objectives: 9 Describe the collaboration needed among team members to support children diagnosed with RAD Method of Presentation: Lecture, large group discussion Materials Needed: 9 Flip Chart Pads 9 Flip Chart Stands 9 Laptop 9 LCD Projector/Screen 9 Markers 9 Masking Tape/Poster Putty 9 Handout #1: Agenda/Idea Catcher (revisited) 9 Handout #7: Focus of Treatment 9 PowerPoint Presentation: o Slide #19: Collaboration Techniques to Create a Team Approach o Slide #20: Focus of Treatment o Slide #21: Collaboration with Caseworker and Mental Health Therapists o Slide #22: Collaboration with Birth Parents o Slide #23: Collaboration with Medical Personnel o Slide #24: Collaboration with Occupational Therapist o Slides #25-26: Collaboration with Educators o Slide #27: Remember 9 Trainer Resource: Bomber, L. M. (2007). Inside I’m Hurting: Practical Strategies for Supporting Children with Attachment Difficulties in School. London, UK: Worth Publishing, Ltd.
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions Section V: Collaboration: Creating a Team Approach Step 1: Focus of Treatment (15 Minutes) Display PowerPoint Slide #19 (Collaboration Techniques to Create a Team Approach) and explain that this section of the training focuses on the level of collaboration needed among Resource/Adoptive families, caseworkers, birth families, therapists, medical personnel, and educators to support children diagnosed with RAD. Teaming is a value and principle of the PA Child Welfare Practice Model. Teams include both formal and informal supports and resources; and each team member should have an equal role and voice in decision-making and collaborating on common goals. Distribute Handout #7 (Focus of Treatment). Display and review Slide #20 (Focus of Treatment). Refer participants to Handout #7 (Focus of Treatment) and ask which treatments are familiar and unfamiliar to them. Explain that the goal of attachmentbased therapies is to help children attach to their primary caregiver(s). Note that there is a history of controversies over the methods some therapists have used to promote attachment (rebirthing, etc.), but that recommended attachment-based therapy seeks to reduce the “alarm reaction” and promote self-regulation in the child. It provides structure and sets limits on the child’s acting out behaviors in a safe and nurturing environment. Explain that children diagnosed with RAD and related disorders often experienced trauma due to neglect, abuse or exposure to other types of violence in their environment (National Child Traumatic Stress Network, 2013a; Substance Abuse Mental Health Services Administration, 2012). Some types of attachment-based therapies integrate treatment of trauma, but children’s trauma(s) are sometimes addressed separately through art therapy, play therapy, equine therapy or psychotherapy (National Child Traumatic Stress Network, 2013b). Explain that a more recent, neurologically-based approach for treating trauma is Eye Movement Desensitization Reprocessing (EMDR). EMDR uses rhythmical stimulation such as lightly tapping the child’s left then right arm repeatedly to change how the brain processes information, and to change the way the nervous system takes in and interprets information. It reduces the “alarm reaction” and chronic levels of hyper vigilance in the child. Although neuroscientists and other researchers are still exploring the exact reason why EMDR works in healing trauma, it has a record of success in treating war veterans and first responders diagnosed with Post Traumatic Stress Disorder (PTSD). Explain that children diagnosed with RAD and related disorders sometimes experience problems processing information coming in through the five senses (sight, sound, taste, smell, and particularly touch), movement of their bodies in space, and balance. This can sometimes stem from lack of stimulation as an infant or young child due to neglect. The Pennsylvania Child Welfare Resource Center
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions Specially trained Occupational Therapists (OT) can help children smoothly integrate their sensory systems and reduce the fight/flight response (sensory defensiveness) to many of the sensations that are imposed on them throughout the day. Sensory defensiveness can cause a child to behave in aggressive or avoidant ways. Explain that there is no specific type or family of medications used to treat children diagnosed with RAD. Instead, medications are used to treat specific related conditions such as chronic sleep disturbances, anxiety, depression and hyperactivity. Step 2: Collaboration (20 minutes) With all team members, it is important to remember that open communication is key in providing consistency in treatment and parenting. Team meetings keep everyone on the same page and ensure the correct behavior responses are being used consistently across all contexts of the child’s life. Trainer Note: Remind participants that they may follow along on their power point presentation handout, Handout #3. Display and review Slide #21 (Collaboration with Caseworker and Mental Health Therapists). It is crucial to include mental health experts and caseworkers as part of the team. The focus of parents/caregivers teaming with the caseworker and mental health therapist(s) should remain on safety, promoting healthy attachment, and healing any trauma experienced by the child. Parents/caregivers should ask for specific ideas to address the behaviors exhibited by your child. Keep safety (for child and all family members) and supervision needs at the forefront of discussions. Display and review Slide #22 (Collaboration with Birth Parents). Birth parents are a key member of the team and play a critical role in helping the child heal old wounds, experience smoother transitions, and feel supported in the permanency plans that are in place (Child Welfare Information Gateway, 2013). While the levels of openness between the child’s birth family and resource/adoptive families may vary greatly, promoting and strengthening these connections creates the opportunity for a number of potential positive outcomes (Child Welfare Information Gateway, 2013). A number of advantages exist for birth families, adoptive families, and children (Child Welfare Information Gateway, 2013). Among the findings of potential outcomes for adopted children are: establishing a sense of connection and belonging; gaining access to important genetic and medical information; developing a deeper understanding of their identity and a greater sense of wholeness; preserving connections not only to family but also to their cultural and ethnic heritage; developing a better understanding for the reasons for placement, which can lessen feelings of abandonment; and relating to birth family members as real people with strengths and flaws rather than idealized or overly negative fantasies (Child Welfare Information Gateway, 2013). The Pennsylvania Child Welfare Resource Center
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions Children in foster care also reap benefits as well from maintaining regular, continuous connections with birth parents and siblings while in placement as part of permanency planning. Utilizing a team approach during transitions from the foster home to their birth families gives children what they need to “shift gears,” validates their feelings, and provides structure to promote higher levels of security (National Resource Center for Permanency and Family Connections, 2012). Display and review Slide #23 (Collaboration with Medical Personnel). Physicians bring a unique and valuable perspective to the team. The pediatrician can track the child’s growth and development, and offer guidance and treatment if the child is experiencing problems with eating, sleeping, or anxiety. Also, pediatricians are typically the starting point for referrals to specialists and further evaluation when needed. Display and review Slide #24 (Collaboration with Occupational Therapists). Children diagnosed with RAD often also have what is known as Sensory Processing Disorder (hyper or hypo sensitivity to incoming stimuli from one or more of the senses). Explain that a number of Occupational Therapists specialize in working with children and infants who have difficulty smoothly integrating input from the seven senses of sight, sound, taste, smell, touch, vestibular (balance and movement), and proprioceptive (body positioning in relation to people and objects). During the OT sessions that are typically weekly or bi-weekly, the therapist uses planned activities that help the child gradually process the information coming into the brain from one or more of these senses. For example, the OT will use a soft toothbrush on a child’s leg or arm (sometimes referred to as “brushing”) to increase tolerance for touch and to help the child’s brain integrate the sensation of touch. These sessions with the OT are typically held in hospital outpatient clinics or private agencies, although children under the age of three may qualify for in-home services from an OT as part of Early Intervention Services. Regardless of where the therapy occurs, the OT will recommend that specific, similar activities be carried out at home in between the scheduled appointments. Explain the importance of maintaining the schedule of OT appointments to maximize the rate of progress and the need to follow through on “homework” recommended by the therapist to reinforce progress made in the OT sessions. Occupational Therapists will often ask parents to use specific techniques with the child at home such as “brushing” to help the child tolerate increasing levels of nurturing touch. The OT may also prescribe the use of a weighted vest or blanket for specified periods of time during the day to help children calm their sensory systems and self regulate more easily. Follow the guidelines for using regulation supports (weighted vest and blankets) if prescribed by the OT, and continue to collaborate with the caseworker and educators when the regulation supports are recommended for use in settings outside the home.
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions Display and review Slides #25-26 (Collaboration with Educators). Explain that the diagnosis of RAD and/or other related disorders can sometimes qualify the child for a 504 Plan and/or an Individualized Education Plan (IEP) under the special education category of Emotional and Behavioral Disorders. A 504 Plan and/or an IEP can provide accommodations at school to prevent or reduce misbehaviors and develop consistent, positive supports to increase academic success. If a plan is in place, ensure that the recommended accommodations are consistently used at school by attending team meetings, communicating regularly with teachers, and tapping advocacy sources that are available if needed. Examples of behavioral accommodations include cueing the child to calming throughout the day, using the “short and sweet” approach in response to misbehaviors, and adjusting expectations to match the child’s ability to connect consequences following misbehavior. It is important that treatment recommendations by any of the professionals discussed here, or any additional team members, are presented to and discussed by the entire team. Display and review Slide #27 (Remember) to capture the key points of this section. Ask participants to use Handout #1 (Agenda/Idea Catcher) to capture key learning points from this section of the training. Ask participants to share what they wrote on the handout.
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions Section VI: Closing and Evaluations Estimated Length of Time: 20 minutes Learning/Performance Objectives: 9 List key concepts learned Method of Presentation: Lecture, small and large group discussion Materials Needed: 9 Flip Chart Pads 9 Flip Chart Stands 9 Laptop 9 LCD Projector/Screen 9 Markers 9 Masking Tape/Poster Putty 9 Trainer-Prepared Flip Chart: What’s In It for Me? 9 Trainer-Prepared Flip Chart: Parking Lot 9 Handout #1: Agenda/Idea Catcher (revisited) 9 Handout #8: Action Plan 9 Handout #9: Resources 9 Handout 10: References 9 PowerPoint Presentation: o Slide #28: What’s the #1Take Away Idea for You? o Slide #29: Getting Support o Slides #30-31: Useful Websites o Slide #32: Additional Readings
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions Section VI: Closing and Evaluations Step 1: What’s In It for Me and Parking Lot Review (5 minutes) Engage participants in a discussion pertaining to their experience throughout the training, validate, and thank participants for sharing. Ask participants to think about what they learned during the training and share what they gained from it. Review the What’s In It For Me? flip chart making sure that all points were addressed. Review the Parking Lot flip chart and assist participants in identifying any possible resources that may meet their needs. Trainer Note: It may be beneficial to compile some questions for the group to help with the discussion of the overall experience throughout the training. Step 2: Action Planning and Additional Resources/Materials (5 minutes) Display PowerPoint Slide #28 (What’s the #1 Take Away Idea for You?). Ask participants to review what they wrote on Handout #1 (Agenda/Idea Catcher) at the end of each section of the training. Summarize key learning points shared by the participants and get participants’ feedback on the content of the presentation. Distribute Handout #8 (Action Plan) and ask participants to identify ways in which they plan to use the content of the training in their parenting. Display and briefly reference PowerPoint Slide #29 (Getting Support), PowerPoint Slides 30-31 (Useful Websites), and PowerPoint Slide #32 (Additional Readings). Distribute Handout #9 (Resources). Note that the content on these slides and handouts can help parents tap into local and internet sources of support, and find information in addition to what was provided in the training. Step 3: References and Evaluation (10 minutes) Distribute Handout #10 (References). Tell participants that these are the references used to write this curriculum. Participants should feel free to review them whenever time allows. Distribute the course evaluations and ask participants to complete them. Thank participants for participating in the training.
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921: Reactive Attachment Disorder: Parenting and Therapeutic Interventions References American Psychiatric Association. (2013). Diagnostic Statistical Manual (5th Edition). Washington, DC: American Psychiatric Association. Bomber, L. M. (2007). Inside I’m Hurting: Practical Strategies for Supporting Children with Attachment Difficulties in School. London, UK: Worth Publishing, Ltd. Cline, F., & Fay, J. (2006). Parenting with Love and Logic. Colorado Springs, CO: NavPress. Cross, K. (2003). Dyadic Developmental Psychotherapy. Wichita, KS: Attachment Center of Kansas. Retrieved from http://www.ksattach.us/kimcrosslscsw.htm. Levy, T. M., & Orlans, M. (1998). Attachment, Trauma, and Healing: Understanding and Treating Attachment Disorder in Children and Families. Washington, DC: Child Welfare League of America, Inc. Mayo Clinic. (2013). Reactive Attachment Disorder. Retrieved from http://www.mayoclinic.com/health/reactive-attachmentdisorder/DS00988/DSECTION=risk-factors. National Institute of Mental Health. (2013). Mental Health Medications. Retrieved from http://www.nimh.nih.gov/health/publications/mental-health-medications/completeindex.shtml Perry, B. D., & Szalavitz, M. (2006). The Boy Who Was Raised as a Dog: And Other Stories from a Child Psychiatrist's Notebook: What Traumatized Children Can Teach Us About Loss, Love and Healing. New York: Basic Books. Scattergood Ethics Institute. (September 16, 2011). Categories and Controversies: The Ethical Dimensions of the DSM-5. Philadelphia, PA: University of Pennsylvania Center for Bioethics. Siegel, D., & Hartzel, M. (2004). Parenting from the Inside Out: How a Deeper Self-Understanding Can Help You Raise Children Who Thrive. NY: Penguin Books. Siegel, D., & Solomon, M. (2003). Healing Trauma: Attachment, Mind, Body, and Brain. NY: Norton & Company, Inc. Thomas, N. (1997). When Love Is Not Enough: A Guide to Parenting Children with RAD. Glenwood Springs, CO: Families by Design. The Pennsylvania Child Welfare Resource Center
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