By Chuck Geddes, Ph.D.
Complex Care and Intervention (CCI) model
In our clinical work we are often referred children or youth from our foster care system or from stressed adoptions who exhibit extremely challenging behaviour and who seem to have a bewildering array of difficulties. The children often arrive with a long list of diagnoses and an equally long list of “what hasn’t worked”. It’s not uncommon to encounter committed caregivers who are at their wit’s end and are on the verge of giving up. Fortunately, we have witnessed our Complex Care and Intervention (CCI) model work time and time again so we are able to offer hope. The CCI model is built on a deepening understanding of the effect of complex trauma in children’s lives, and the effect that this has on their brain and nervous system development.
An Intervention Plan
Our therapeutic model begins with teaching the responsible adults involved with the child or youth about complex trauma. We then move to a specialized assessment called the Functional Developmental Assessment which is a type of structured group interview about the child. We chart the child’s development across seven Developmental Domains and use this information to develop a child-specific intervention plan. Our plans include ideas on how to create developmental opportunities and experiences which will help the child or youth to grow in their capacities in such things as emotional regulation and behavioural regulation. One of the things that we love to watch is how, once the team of adults understands the intervention concepts and principles, they begin to generate ideas on how to create simple day to day therapeutic experiences. The teams love the idea that they are helping to “change David or Jennie’s brain”.
In keeping with what we’ve learned from Dr. Bruce Perry and the Child Trauma Academy, we often find that our first priorities are to help to calm the child’s over-reactive stress response and to provide positive attachment experiences geared to the particular attachment style and needs of that child. Within CCI we have referred to these as the “Therapeutic Bookends” of Decreasing Stress and Strengthening Attachment. What we have seen over and over again is that if our plan addresses both of these we will be successful. If we miss either one, we will usually not be successful. As one of the therapeutic bookends, the overall stress/arousal/anxiety level of the child is often the priority target for intervention. If we don’t address this heightened arousal, then other efforts will often prove to be ineffective or fruitless – as may have often been the case in working with the child up to this point. Exposure to traumatic experiences and toxic stress often leave the child’s stress response system set permanently on high alert, and prone to suddenly throw the child into a Fight or Flight response. Adults working with these kids say things like “One minute everything is okay and the next moment he has snapped and is yelling and spitting and angry. It’s like they he’s lost his mind!” Or, “She seems to be okay and then without warning she’s throwing things at the other kids and running around the room. It’s like she goes from zero to 60 in the blink of an eye.”
This makes complete sense from a complex trauma perspective. The child’s alarm system is set on high alert and they respond to stress in a much more sensitized way than other children. They are both more sensitive to certain things as being stressful or making them afraid (e.g. the look on an adult’s face) and more prone to over-reacting to this perceived threat. Our CCI approach places the responsibility for reducing stress and hyperarousal on the adults around the child. Creating predictable routines and daily/weekly schedules helps. Carefully preparing the child for upcoming transitions and activities helps. However, we’ve found that many caregivers already try to do these things. We become detectives, looking for the events or activities in the week that seem to cause the child stress, and we are diligent in reducing and carefully planning for stressful situations such as family visits, school, or peer interaction.
Some of these steps seem counter intuitive at first and to some it may seem that we are coddling the child. We speak instead of trying to, as one of our parents says; create “Mary-sized challenges”. Our view is that not only is the child’s stress response system set on high alert, but it rises and stays high for days after stressful events, in effect undermining all the efforts of caring adults throughout the week. The evidence is very strong – once we’ve worked to reduce or remove stress we usually see immediate gains. The child is more able to cope, and there are less meltdowns. Parents and caregivers find themselves coming down from their own heightened stress responses. The kids begin to experience more success. What’s even more amazing is to see positive changes in things like sensory sensitivities, a decrease in tics, and a decrease in what seemed like serious mental health symptoms such as cutting or even hearing voices.
Please come back for the 2nd part in this blog series – Therapeutic Bookends: Strengthening Attachment
If you’d like more information on Decreasing Stress or in depth discussion on quieting the stress-alarm system you may wish to consider joining CTR as a member.
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