Books and Methods Review - Trauma and Reactive Attachment Disorder

The way the world looks at Reactive Attachment Disorder (RAD) has changed over the years. Parents are often told that it is "rare" and most diagnosticians are reluctant to diagnose. The reality is that while it may be rare in the general population, for those of us dealing with adopted and foster children, it is far less "rare" and I would say, it is common. 

DSM-5

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition has changed the definition of RAD. While Reactive Attachment Disorder (RAD) still exists, it is now used to describe "Inhibited RAD." What used to be called "Disinhibited RAD" is now called Disinhibited Social Engagement Disorder (DSED).  {More info below}

So What Do You Look For? A List for Recognizing Trauma & Attachment Issues 

by Beyond Trauma and Attachment and  Dr. Arthur Becker-Weidman

The following list of often-experienced behaviors of traumatized adopted children was developed by Dr. Arthur Becker Weidman, Ph.d.  He has studied attachment and complex trauma especially in children who were adopted after the age of 18 months.  If you are an adoptive or foster parent and you can check off more than a few of the characteristics on this list, you may have a child with attachment and/or complex trauma issues.

1. My child acts cute or charms others to get others to do what my child wants.
2. My child often does not make eye contact when adults want to make eye contact with my child.
3. My child is overly friendly with strangers.
4. My child pushes me away or becomes stiff when I try to hug, unless my child wants something from me.
5. My child argues for long periods of time, often about ridiculous things.
6. My child has a tremendous need to have control over everything, becoming very upset if things don't go my child's way.
7. My child acts amazingly innocent or pretends that things aren't that bad when caught doing something wrong.
8. My child does very dangerous things, ignoring that my child may be hurt.
9. My child deliberately breaks or ruins things.
10. My child doesn't seem to feel age-appropriate guilt when my child does something wrong.
11. My child teases, hurts, or is cruel to other children.
12. My child seems unable to stop from doing things on impulse.
13. My child steals, or shows up with things that belong to others with unusual or suspicious reasons for how my child got these things. {Handling Lying and Stealing}
14. My child demands things, instead of asking for them.
15. My child doesn't seem to learn from mistakes and misbehavior (no matter what the consequence, the child continues the behavior).
16. My child tries to get sympathy from others by telling them that I abuse, don't feed, or don't provide the basic life necessities.
17. My child "shakes off" pain when hurt, refusing to let anyone provide comfort.
18. My child likes to sneak things without permission, even though my child could have had these things if my child had asked.
19. My child lies, often about obvious or ridiculous things, or when it would have been easier to tell the truth.
20. My child is very bossy with other children and adults.
21. My child hoards or sneaks food, or has other unusual eating habits (eats paper, raw flour, package mixes, baker's chocolate, etc. ) {Food/ Hoarding/ Diet}
22. My child can't keep friends for more than a week. {"Kleenex Girls"}
23. My child throws temper tantrums that last for hours.
24. My child chatters non-stop, asks repeated questions about things that make no sense, mutters, or is hard to understand when talking.  {Therapeutic Parenting - Nonsense Questions and Chatter}
25. My child is accident-prone (gets hurt a lot), or complains a lot about every little ache and pain (needs constant bandaids). (Even though he/she may not complain about serious injuries or illnesses - Psychosomatic "Illnesses"}
26. My child teases, hurts, or is cruel to animals.
27. My child doesn't do as well in school as my child could with even a little more effort.
28. My child has set fires or is preoccupied with fire.
29. My child prefers to watch violent cartoons and/or TV shows or horror movies (regardless of whether or not you actually allow your child to do this). {Media and RAD}
30. My child was abused/neglected during the first year of life and/or had several changes of primary caretaker during the first several years of life. (This can include multiple or extended hospitalizations)
31. My child was in an orphanage for more than the first year of life.
32. My child was adopted after the age of eighteen months (It is possible to have RAD even if the child was adopted at birth - if the child was "pickled" in utero with drugs, alcohol, and/or stress hormones...).

This video gives a good description of RAD symptoms (heads up - lots of Christian faith mentions)

{Marythemom--I do not agree with everything in this video - particularly his claim that EVERY adopted child has RAD. I do believe that every foster/ adopted child has experienced trauma of some sort - just being adopted or in foster care means that there has been a traumatic break from the birth family)}

Attachment Disorders and Post Traumatic Stress Disorder should be viewed on a continuum. 

Symptoms can be mild and healed relatively easily - or extreme and complex.   Post-Traumatic Stress Disorder is usually caused by a significant traumatic event or two.  Complex PTSD is usually caused by years of traumatic events, like a child abuse victim.  Reactive Attachment Disorder is the extreme end of attachment disorders and usually causes permanent brain damage.  {Chronic Post-Traumatic Stress Disorder (C-PTSD)}

 Reactive Attachment Disorder is usually associated with some form of abuse or neglect in the first two to three years of life. This normally involves physical or emotional abuse, abandonment, a drug-addicted caregiver, a sequence of foster placements, or similar emotional trauma. In some cases, children may have symptoms of an attachment disorder if they have experienced divorce, long periods of hospitalization, a parent with chronic depression, or if their brains were altered by the mother's substance abuse.

The most common factor for children with attachment disorders is that in the critical first years of life, either the child did not have the opportunity to bond emotionally with any single individual and maintain that bond, or the child did experience an emotional attachment and then was separated from the caregiver. ~  Strategies for Classroom Teachers of Students with Reactive Attachment Disorder

According to the DSM IV-TR, There are two types of Reactive Attachment Disorder:

 Disinhibited Type:

• Being way too “cute” and charming, especially as a means to get what they want, whether it is attention or material objects/food.
• Acts like a baby/uses the “baby voice” and behaves inappropriately younger than their age.
• Exaggerates about everything, especially their “need” to be helped.  
• Easily/readily goes off with strangers and/or seeks affection (i.e. hugs) from strangers.
• Makes friends with a lot of other children (usually younger than themselves), but is not very close to any one of them.
• Talks a lot – asks a lot of “crazy” questions 
•  Makes up stories – long, long, stories.
•  Wants just about everything they see and feels “unloved” when they do not get it.
•  When they do get the item, pays attention to it for only a short while and then either breaks it or puts it away and ignores it/forgets about it (unless you try to get rid of it, then they desperately love it!). {Decluttering}

Inhibited Type:

• Avoids relationships and is in a constant pull-push mode with the people trying to be close to him, such as parents.  (Gets close enough to get what he wants, then pushes away again.)
• Resists affection / stiffens when you try to hug them.
• Avoids eye contact (unless lying, then will look you straight in the eye and forcefully deny anything, even obvious things).
• Is always “on guard.”  (Whenever you want to talk with them, they get defensive and think they’re in trouble.)
• Keeps score.  Knows exactly what he “got” vs. what his brother got for birthdays, Christmas, etc.
• Has very few friends.  The friends he does have are not all that close.
• Prefers to be alone.
• Lies a lot.  “Crazy lies” about things that do not matter.  Believes own lies. {Lying and Stealing}
• Engages in self-soothing behaviors rather than seek comfort from parents.

Either type:

• May hoard food, trash. {Food}
•  May steal. {Lying and Stealing}
•  May argue about ev.e.ry.thing.
• May act completely different than the type they usually exhibit.  (Ex.  a disinhibited child may shut down and be surly from time to time, while an inhibited child may occasionally act silly and much younger than his/her age.)

Trauma Triggers
A child whose past trauma is triggered will likely exhibit several of these signs at one time, and they may be even more exaggerated than usual.  Kids can be triggered by sights (violent TV shows, someone who looks like a past abuser, a situation that reminds them of a traumatic event), smells (fried potatoes), sounds (a full laundry basket falling to the ground, a siren, a fire alarm at school, or a loud/sharp yell), and sensory feelings (a certain touch, a particular fabric, cold weather).   

They can also be triggered by "traumaversaries" anniversaries of significant events (like entering foster care), birthdays, and holidays. {Holidays, Birthdays, and Other Traumaversaries}

{How We Handled It - Calming/ Relaxation Techniques Handling Dysregulation/ Meltdowns Handling Rages}

Female Caregivers (the "Nurturing Enemy")
A common defense mechanism for our kids is to try to leave before what they believe is their "inevitable" abandonment by us. Attachment and people loving them is scary. Especially love from the female caregivers - they push us away the hardest of all. They try to move on before things get emotional. Demanding that they want to be put into a new family, foster care, group home... somewhere else, where everything will be "better."

 “Nurturing Enemy” - Our kids tend to behave differently (usually worse) with the female caregiver. In their mind, the mother is the person that hurt them the most, that can hurt them the most. They turn their hatred and loss they feel towards their birth mothers abandonment and abuse toward us. 

Even though we have never hurt them (and never would!), sometimes they get stuck in the past. Often with my kids, it was because things that happened to them before they came to us, got their feelings and the events of their childhood mixed up with me as their mother figure. I know some kids talk about things that they remember having happened to them as a child, as though it had happened recently.


Another thing about their issues with mothers is that we're almost always the ones "forcing" them to deal with attachment and feelings,

Why Does My Child Act Differently With Everyone Else? 


Changes from the DSM IV-TR to the DSM V - American Psychiatric Publishing

DSM-IV  Reactive Attachment Disorder
The DSM-IV childhood diagnosis Reactive Attachment Disorder had two subtypes: emotionally withdrawn/inhibited and indiscriminately social/disinhibited.

DSM-5  Reactive Attachment Disorder and Disinhibited Social Engagement Disorder
In the DSM-5, these subtypes are defined as distinct disorders: Reactive Attachment 
Disorder and Disinhibited Social Engagement Disorder. Both of these disorders are the result of social neglect, trauma, or other situations that limit a young child’s opportunity to form selective attachments.

Although sharing this etiological pathway, the two disorders differ in important ways. 

Because of dampened positive affect (ex. they don't show their feelings with body language), Reactive Attachment Disorder more closely resembles internalizing disorders; it is essentially equivalent to a lack of or incompletely formed preferred attachments to caregiving adults. 

In contrast, Disinhibited Social Engagement Disorder more closely resembles ADHD; it may occur in children who do not necessarily lack attachments and may have established or even secure attachments.

The two disorders differ in other important ways, including correlates, course, and response to intervention, and for these reasons are considered separate disorders.

Reactive Attachment Disorder - DSM V
Diagnostic criteria for RAD:

• A consistent pattern of emotionally withdrawn behavior toward caregivers, shown by rarely seeking or not responding to comfort when distressed
• Persistent social and emotional problems that include minimal responsiveness to others, no positive response to interactions, or unexplained irritability, sadness or fearfulness during interactions with caregivers
• Persistent lack of having emotional needs for comfort, stimulation and affection met by caregivers, or repeated changes of primary caregivers that limit opportunities to form stable attachments, or care in a setting that severely limits opportunities to form attachments (such as an institution)
• No diagnosis of autism spectrum disorder

Disinhibited Social Engagement Disorder - DSM V

A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following:

• Reduced or absent reticence in approaching and interacting with unfamiliar adults.
• Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries).
• Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
• Willingness to go off with an unfamiliar adult with little or no hesitation.

B. The behaviors in Criterion A are not limited to impulsivity (as in Attention-Deficit/Hyperactivity Disorder) but include socially disinhibited behavior.

C. The child has exhibited a pattern of extremes of insufficient care as evidenced by at least one of the following:

• Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation and affection met by caregiving adults.
• Repeated changes of primary caregivers that limit ability to form stable attachments (e.g., frequent changes in foster care).
• Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios).

D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).

E. The child has a developmental age of at least nine months.

Specify if Persistent: The disorder has been present for more than 12 months.

Specify current severity: Disinhibited Social Engagement Disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.

Another post on RAD - Psychoses or Syndrome?

Online Support and Resources
Wikipedia definition 
Mayo Clinic definition
American Academy of Child & Adolescent Psychiatry 
Medline Plus

Where can I go for help, support, or to learn more about parenting a child with RAD?
My Top 10ish Things I Couldn't Do This Without
Parenting Attachment-Challenged Children and other Facebook groups!
Christine Moers

Dear Bear,

I wrote this letter while waiting for Kitty, who was at equine therapy.  The 45 minute each way trips, often turn into "Dreamkiller" conversations. :(  I decided to have her read the letters "to make sure it made sense."  I hadn't intended for her to read it out loud, but that's what she chose to do.  We had a pretty decent conversation afterward, so this letter may have served more than one purpose!  

Dear Bear,

I hope you're doing OK.  I talk to you on the phone so often that I almost have nothing left to say here!  :)  I miss you; we all miss you a lot.  We think about you often and there are a lot of people praying for you.

I opened my Bible today to look for a verse about forgiveness for you, since forgiveness is something you ask for often in your letters, and this verse jumped out at me.

Your families... shall rejoice in everything you have put your hand to, because the Lord your God has blessed you.  (Deut. 12:7 NIV)

This may seem like a weird quote to send to your son while he's in jail, but it's true.  While I wish this hadn't happened, I also choose to see it as happening for a reason.  I don't know what that reason is, and I may never know, but I believe God has a plan for you, just like he does for me.

God has allowed me to make big mistakes.  He's allowed others to hurt me; I could believe that that means he doesn't give a crap about me - and for a long time I did.  I threw God, my dad, and a lot of other people out of my life, because they weren't doing what I wanted/expected them to do.  I wanted my dad to be a warm, loving parent, who was always there for me... and he just wasn't capable of that.  I pushed Hubby away because I couldn't/ wouldn't trust him.  Like everyone else, he's human, and made mistakes.  I finally had to accept that no one could love me the way I thought love should be.  I had to learn to love myself, flaws and all, before I was ready to love another imperfect human.

You are lucky.  You accepted God/ Christ into your life at a young age.  He has forgiven you your sins and continues to forgive you for your mistakes.  All you have to do is ask - and believe!

Honey, you don't need to keep asking for our forgiveness either.  We have forgiven you!

Now you need to accept that forgiveness and move on.  Your past is over.  You are a new creature, blessed by God, loved by many.  Learn from your mistakes, and all the ones you will make in the future (as a wonderfully, God-made human), and use them to make yourself a better human, citizen, son, husband, lover, father, employee, brother, mentor, Christian...

We are all sinners.  We have all had horrible things happen to us.  Use this knowledge to be an understanding, caring witness to those around you.  I know you are capable of being a warm, loving, helpful witness to others.  Use your talents:  caring for others, protecting those weaker than you, understanding others who've been through some of the things you've been through and help them.  By doing this, you will become the person I know you to be.  The person you couldn't be if you hadn't experienced all that you have.

I know YOU! - The kid that is smart, funny, helpful, caring... Yes, you've made mistakes and not so great choices.  This does not mean you are a bad person.  You are human!  I know you are strong enough to turn this into a positive, learning experience.

When you come home, be aware that it is going to take time to show everyone that you've changed.  I know you know how hard it is to trust someone who hurt you.  I know you won't use this as an excuse to toss that person out of your life.  I know you will do the hard work to rebuild that trust, make amends (restitution), and feel sympathy toward them as they work hard to trust you.

I believe you are capable of doing the hard work it's going to take to get the help, and accept the help, that you'll need to become the man that God wants/ expects.

I promise to help you in every way I can to achieve this goal.

Because I love you!

I have sent your letters to {ex-girlfriend here in Texas}.  She still cares about you, but Bear, I hope you will give yourself time to work on yourself and learning how to be a strong, healthy person with the skills needed for being in a relationship - FIRST!  I think you need to get back into therapy and work on your past relationships with your family (bio and adopted) before you're ready for a relationship with a woman.  Having had my own attachment disorder, I hope you will believe that this is something I understand, because I've been there.

I want you to have a good, strong, happy relationship and a family of your own, but you have plenty of time for that.  You're not ready yet.  You will be, but please give yourself some time to heal and grow before you become responsible for others' hearts.  I know you're lonely.  We all want the "They lived happily ever after," but that's just a fairy tale.  In real life, Cinderella married a guy with a totally different life, that she met once, at a party.  They now have to deal with her family issues, his expectations (he thought she was a princess so rich and pampered that she wore glass shoes!), her expectations (should she get a job, who will take care of all her rodent friends - RATS! - will they move to the palace?  What if the prince doesn't like her friends?)  This relationship is pretty much doomed... unless they get more help from a genie or fairy therapist. :)

My hope for you is that you'll get back on your meds, get back in therapy, accept help and give yourself some time before you try to become an independent, responsible adult.  Not everyone has the chance to take this time... you do.  Just like the bear in the story they wrote for you at {the place that took months and did a thorough neuropsych almost 2 years ago}, you have a chance to do a little more growing, to make up for the time you lost as a child, not getting to be a child.  I hope you've learned that being a responsible adult is hard work that maybe you weren't quite ready for.

You rushed into adult life; you had to do a lot of growing up fast when you were a child.  That's not fair, and you missed out on some of the important steps and some of the fun stuff too.  Please take this chance with us to wait a little longer before you grow up!

This is a long letter, so I'm going to close with the verse my Bible opened to when I was flipping around, looking for just the right thing to say to close this letter.  Couldn't believe how appropriate it was - normally I don't recommend looking for solutions by randomly opening the Bible, but I think God was trying to send you a message:

The God of All Comfort

3Praise be to the God and Father of our Lord Jesus Christ, the Father of compassion and the God of all comfort, 4 who comforts us in all our troubles, so that WE can comfort those in any trouble with the comfort we our selves have received from God. (2 Corinthians 1:3-4)

I have often wondered if one of the reasons you are there is to help and comfort those around you.

Love always,
Mom
(And Hubby, and Bob, Ponito and Kitty)

The RAD Stink

We call it the "RAD Stink." You've heard of the "smell of fear"? Well, the smell of dysregulation in attachment-disordered kids can smell like feces and the worst body odor you can imagine. 

"This is just a thought and not based on any scientific anything but, if our body uses/produces hormones when under stress and stress is a toxin to the body - then that toxin overload having a bad smell is not too surprising, is it? I sometimes think of our RADlings as a wild animal that has gotten cornered with no way out. Think of what that wild animal would look like - think of how that wild animal would respond to any attempt you would make to get close to it - now think if that animal was a skunk - yeah.....that folks is our Radlings!! Poor babies!! We are trying to care for the love child of a porcupine and a skunk....and we don't want to get hurt or smell bad in the process. It just can't happen."  ~ A Trauma Mama

When we first smelled this foul odor coming from Kitty, we assumed Kitty was lying about bathing and hygiene, wearing dirty clothes, and/or not wiping well (all behaviors that are typical for people who have been sexually abused)... and there was certainly evidence of that. In her former foster home, she’d had major problems with encopresis that was determined to be behavioral (but we discovered later could have had a physiological source).

One year when Kitty was really emotionally unstable, her school sent her home several times because the other kids and teachers couldn't tolerate the smell (to the point that they were gagging and nauseous).  We did everything we could think of to help her. We kept a change of clothes at school and the school sometimes had her use alcohol-based waterless hand soap on her underarms (which did help).  At home, I supervised her showers (as much as possible without invading her privacy), making sure she shaved her armpits, used soap everywhere, and used shampoo. We also checked her bedding (she would often wet the bed and continue to sleep in it night after night).  While she did have issues with all of these, none of them really explained the stink. 

We finally connected that the more dysregulated Kitty became, the worse the stink. That year, she was in and out of psych hospitals. Kitty's smell issues may have improved because we changed her meds, she's slowly healing from the trauma, she's becoming more attached to the family, feels safer, she's older, she's learning to take better care of her body... who knows?

You've heard people say, "He reeked of fear." Her smell was like anxiety pheromones were oozing out of her pores. When she finally got emotionally regulated, the stink dialed back to normal levels (well, "normal" for a teenager with hygiene issues). 

"My kid with RAD (age four at the time) had BO like a teenager. It could knock you over. She only has it now during high anxiety times. She's 8 and not hit puberty, but she can smell rancid, and no amount of showering or deodorant covers it up.

My other kid with less RAD, more FASD, has a different kind of body odor and is often drenched in sweat from high anxiety. His is more of a sweet stench than the other that will make one dry heave." ~ A Trauma Mama

Possible Causes:

• Special Diets/allergies, intolerances - Individuals who are vegetarian, vegan, and omnivores often have distinctive odors from each other. People suffering from allergies and intolerances can have somatic reactions. 
• Change in diet or parasites - particularly children adopted from foreign countries. 
• Medications
• Hormones! You've got to love puberty. *sigh*
• "RAD odor" - A lot of people talk about a specific RAD odor that ALL RAD kids have whether from an orphanage, foster care, or family of origin- sometimes compared to animals who use smell defensively. It's in their hair, their skin, their used clothing, and doesn't alleviate until they've been in attachment therapy for a long time and are attaching to their family. The theory being that they subconsciously want to push everyone away.  It's often worse when they are dysregulated.
• "Smell of fear" - you've heard people talking about the smell of fear, I imagine this would be particularly intensified in a child of trauma
• Stress/nervousness - many children interpret the world differently and feel criticized and attacked constantly. The body does strange things under stress (hand and body sweating, intestinal gas, nervous tics...). Gassy/ potty smells  - stress can cause the digestive system and gastrointestinal issues to flare.
• Waste disposal - our bodies also release waste through the skin, particularly the soles of the feet and the palms of the hands.
• Underwear issues - many kids don't wipe, Kids who are frequently constipated might "leak" during the day.
• Hydration issues - many parents talked about the fact that their child's urine was much stronger smelling than normal. This could be in part to not drinking enough which would concentrate the urine,
• Hygiene Skills - maybe the child doesn't know how to properly clean themselves, brush his/her teeth, or when to change undergarments. Kitty once went almost 6 months using only conditioner with no shampoo (we found out when she told the hairstylist who was cutting out the ratty knots in her hair). Can unwashed hair grease go rancid? How can we be sure the child is washing his/her hair all the way down to the scalp?
• Forgetful poor self-care/hygiene. The child might forget or get distracted from taking care of themselves and their hygiene. 
• Deliberately poor self-care/hygiene. Some children deliberately don't take care of themselves because of control issues, poor self-worth, trying to prove parents will reject them by making themselves objectionable/unappealing...
• Sexually abused children often try to make themselves "less attractive" with poor hygiene. Kitty would sleep in urine-soaked sheets for weeks if they weren't discovered. Bear wore multiple layers of clothing at all times and usually only changed the outermost layer (I refuse to think about how long he wore the same pair of underwear, undershirt, and socks. 
• Stubborness! - Bob once went 6 months wearing Crocs with no socks. The school called me and asked me to pick her up because the other children were complaining of her foot odor (we had to throw the shoes away - even Febreeze and washing them couldn't get the smell out). She ignored me when I told her that kids need clean socks, and more than one pair of shoes to give the other a chance to air out. My kids often got obsessed with one pair of shoes and refused to change them (Bob's Crocs, Ponito's Heelys).
• Laundry - even my neurotypical child is comforted by wearing the same clothes over and over (without washing). He also just reuses socks over and over rather than trying to find clean ones.
• Inability to let go - just like Bear never throws anything away, a lot of children feel that what comes out of them is part of them (flushing BMs can be a traumatic part of potty training). This can lead to food hoarding, pack rats, and even the inability to allow laundry to leave the room to be washed.
• Allergies - food, seasonal, environmental allergies. These can cause all sorts of body reactions - hives, gastrointestinal, foul breath due to sore throats, ear infections... Hubby and Bear are both allergic to underarm deodorant (and all shaving creams), causing big problems, as you can well imagine. Hubby is also allergic to Bromine so most carbonated beverages give him gas issues.
• Masking odors - Bear tends to cover up smells with layer after layer of deodorant/ body wash/ cologne... rather than actually doing a good job cleaning. He frequently walks in a cloud. Not sure why he does this.
• Somatic issues - I know most people would rather not talk about itches, rashes, sores, and pain - especially in "private areas." Our kids often won't tell us anything (whether it's "private" or not). Whether it's because they don't trust us to take care of it, don't feel worthy of proper care, or they actually don't have enough somatic feelings to recognize body pain/discomfort (which is why Kitty's constipation went unrecognized for so many years). We found out about Bear's hemorrhoids because he told the doctor at the RTC - he would never have told us.
• Control issues - there are often very few things children have control over. What goes into and out of their bodies is usually one of the few areas they have control over. Anorexia is VERY common in kids of trauma - not only because they hate their bodies (they often hate themselves, so it's only natural that they hate their bodies), but it is also a major control issue - no one can make you eat (well, not until you get to the hospital stage).

Things that might help:

Attachment Therapy  

Calming/Relaxation Techniques 

Handling Dysregulation and Meltdowns

Underarm - One thing we like is that waterless antibacterial soap. It works well for underarm issues and other stinky areas because it seems to kill the bacteria that make the smell and have fewer allergens (depending on the kind you buy).

Stinky feet - We used the waterless antibacterial soap. Someone suggested soaking smelly feet in black tea or vinegar. I've used bleach water to cure fungus and athlete's foot. Socks and shoes that "breathe" and have as few synthetic materials as possible. Multiple pairs of shoes to give them time to completely dry/air out. Try laundry sheets (like Bounce) in them. Something called Gran's Remedy is supposed to work well.

Laundry - Half a cup to a full cup of vinegar or ammonia in each laundry load might help. I often add hydrogen peroxide to my whites.

Breath and general BO - change in diet, watch for allergies (lactose intolerance is a common one), and carbonated beverages. Check for parasites. Try acidophilus (sp?) which can be found in yogurt and can also be taken as a supplement.

Talk To Your Child's Doctor -  Unusual smells are significant and should always be mentioned to a doctor so they can check and make sure all is well.

"They make hunting products that are very good at removing any scent or stink. Heck, the stuff I use will take the onion or fish smell right off your hands!  

Bleach water will take the stink out of anything plastic!" - a Trauma Papa"

Here's a funny commercial for an "anywhere" and "everything" all-natural deodorant.

Another post on the RAD stink.
Good article about high stress and cortisol.

Books and Methods Review - Books for Children and FAIR Club books

This is by no means a comprehensive list.  Just some good ones.

Books that Heal blog - http://booksthathealkids.blogspot.ca/

Children's Adoption and Foster Care Books

Children's Adoption Books by Age  - Great lists of children's books with mostly Adoption themes categorized by age and/or grade.

Books for Ages 2-4 

Books for Ages 5-8 

Books for Ages 9-12 

Books for Teens & Tweens 

Parents/Teachers Books 

Books used in the FAIR Club:

Marythemom:  I pick up most of my books at the local used book stores.  I'm addicted to kids' books and keep them forever, but I see no point in spending a ton of money on books.  I have a huge selection, but I also downloaded articles and short stories from the internet -- whatever I needed to illustrate a point.

I like using moral tales and bible stories written for children (Veggie Tales are fun too!).  They are usually short and if the child can understand abstract concepts like analogies then we can use these as a basis for discussion.  We use "The Boy Who Cried Wolf" a LOT.  Some of the books I like are:

The Book of Virtues for Young People

The Children's Book of Virtues

The Aesop for Children

Arthur's Really Helpful Bedtime Stories

Berenstain Bears and Little Critter series -
Marythemom - These are simple books with good lessons and entertaining illustrations.  There are over 300 Berenstein Bears books on a wide variety of topics (manners, fighting, greed, messy room...) so I can usually find one that fits our circumstances.  
Berenstein Bears Get in a Fight This book shows how one little incident can snowball into a big fight, and sometimes even draw parents into an argument.
I Was So Mad (Little Critter) Mercer Mayer's very popular Little Critter stars in a picture book about feeling angry. With minimal text and funny illustrations to spell out every new situation, the book shows the Critter family saying no to everything Little Critter wants to do. He can't keep frogs in the tub. He can't help paint the house. Finally, mad at the world, Little Critter announces he will run away. When pals come by and ask him to come and play baseball, our young hero's mood quickly changes. He grabs his bat and heads off for the game, telling himself he can run away another day if he is still so mad.

The Dealing with Feelings/ Children's Problem-Solving Series by Elizabeth Crary:
I'm Proud, I'm Scared, I'm Frustrated, I'm Mad, I Want to Play, I Want it, I'm Furious, Mommy, Don't go!  Children learn by thinking through problems themselves. These books allow the child to make a choice and flip to another page to see the consequences of that choice.
Marythemom:  Remember the old "You Choose the Adventure: books?  I used these when I taught preschool and the kids really liked them.   

The Emotional Impact Series... Great series of books about learning emotional control.

Don't Pop Your Cork on Mondays!: The Children's Anti-Stress Book   I n this very informative and highly entertaining handbook for children, Dr. Adolph Moser offers practical approaches and effective techniques to help young people deal with stress.

Don't Tell a Whopper on Fridays!: The Children's Truth-Control Book The truth may be sacred, but many people--both children and adults--think lying is easier. Some people lie so often that it becomes a habit--a very bad habit--that reduces their own sense of self-esteem and makes others not trust them. In a clear and easy-to-understand narrative, Dr. Moser discusses the problems of lying and the importance of telling the truth. he offers thoughtful examples and suggests ways that can help children tell the truth. Dr. Moser's text is informative, entertaining, witty, and easy to read. David Melton's illustrations are outstanding. They are bright and clever, and often hilarious. Children are sure to love this book. parents are bound to appreciate its common-sense approach. And teachers and counselors will recognize this book as a valuable tool for affecting the lives of children in positive ways.

Marythemom:  Really like this series.  Good, practical advice presented in a fun with with cartoon illustrations.  Other books in this series we don't own, but should:  Don't Feed the Monster on Tuesdays!: The Children's Self-Esteem Book, Don't Rant and Rave on Wednesdays!: The Children's Anger-Control Book, Don't Despair on Thursdays!: The Children's Grief-Management Book,  Don't Fall Apart on Saturdays! The Children's Divorce-Survival Book, Don't Be a Menace on Sundays!: The Children's Anti-Violence Book 

The 7 Habits of Highly Effective Teens: The Ultimate Teenage Success Guide  Being a teenager is both wonderful and challenging. In The 7 Habits of Highly Effective Teens, author Sean Covey applies the timeless principles of the 7 Habits to teens and the tough issues and life-changing decisions they face. In an entertaining style, Covey provides a step-by-step guide to help teens improve self-image, build friendships, resist peer pressure, achieve their goals, get along with their parents, and much more. In addition, this book is stuffed with cartoons, clever ideas, great quotes, and incredible stories about real teens from all over the world. The 7 Habits of Highly Effective Teens will engage teenagers unlike any other book.

Marythemom:  This is an excellent book for older teens, especially if you break it up into sections (it's a lot of information to process).  It was a lot easier read than I expected, especially after reading some of the other 7 Habits books for adults.

Alexander and the Terrible, Horrible, No Good, Very Bad Day  Think, Where the Wild Things Are, without the imagination.  Good illustrations and very descriptive of how we all feel sometimes.

A Big Fat Enormous Lie An empty cookie jar and a little lie that grows into an enormous monster. Marythemom:  Cute illustrations, and works with kids that can get abstract concepts (like a lie can be a monster that grows bigger with the lie).

Handling Your Disagreements (Joy Wilt)  Explains why people have disagreements and how to handle them before disagreements turn into arguments, fights, or scapegoatingThis is one of a series of books that came out in the late 70s, early 80s:  Tuff Stuff:  A Children's Book About Trauma, A Kid's Guide to Managing Money, A Kid's Guide to Understanding Parents, The Nitty-Gritty of Family Life, Making Up Your Own Mind.

Marythemom:  They are obviously a little dated, use a few big words and abstract concepts, and are a little preachy, but overall have some good practical advice.

How Rude!: The Teenagers' Guide to Good Manners, Proper Behavior, and Not Grossing People Out Here's an etiquette book that teens will want to read—because it keeps them laughing, doesn't preach, and deals with issues that matter to them, as teens themselves reported in a nationwide survey.  He starts by explaining why etiquette is important—because people who know how to handle themselves in social situations come out on top, get what they want, feel good about themselves, and enjoy life to the fullest. Fourteen chapters describe the basics of polite behavior in all kinds of situations at home, in school, and in the world.

Teens learn how to be a host with the most (and a guest with the best), what to do (and not do) when going online or waiting in line, how to deal with rude relatives, how to act at the mall and the concert hall, how to make introductions, who invented manners, and much more. Hundreds of "Dear Alex" questions and answers cover everything from dating to breaking up, thank-you notes to table manners, ethnic jokes to social cliques, skateboarding to celebrating. Survey results reveal what teens, parents, and teachers think about manners and why they're important.

How to Behave and Why "No matter where you are or who you are, there are four main things that you have to do if you want to make good friends and keep them.  You have to be HONEST; you have to be FAIR; you have to be STRONG; and you have to be WISE, and there is no good in trying to fool yourself. All that isn't so easy."

In a time when all the rules for raising children have been redefined dozens of times, here is a book for bewildered parents from a simpler time when we all agreed on what was right and what was wrong. First published in 1946, Munro Leaf's How To Behave And Why gives touchingly sincere yet gently funny lessons in Honesty, Fairness, Strength, and Wisdom. Originally intended for the very young, but with meaning for us all, How To Behave and Why is a true classic, charmingly illustrated with childlike drawings, and with a timeless message. It is a sure guide for teaching children (and adults) how to behave.

Marythemom:  A little preachy and not my first choice, but good to use when they've read everything else!

How to Take the Grrrr Out of Anger (Laugh & Learn) - Anger is a part of life. We can’t avoid it, we shouldn’t stuff it, and we can’t make it go away.  Kids need help learning how to manage their anger. This book speaks directly to them and offers strategies they can start using immediately.  Blending solid information and sound advice with jokes and funny cartoons, it guides kids to understand that anger is normal and can be expressed in many ways—some healthy, some not.  It teaches them how to recognize anger in themselves and others, how to handle situations and emotions (loneliness, guilt, frustration, fear) that lead to or mask anger, and how to deal with the anger they feel.  Young readers learn that violence is not acceptable and there are better, safer, more positive ways to resolve conflicts.  They also discover what to do when people around them are angry, how to get help, and how to locate other resources (books, hotlines, school groups) when they need more support.

Marythemom:  These are simple books with lots of pictures.  They give good advice in a "non-preachy" way.  I'd recommend the whole Laugh and Learn series:  Stress Can Really Get on Your Nerves!, See You Later, Procrastinator! (Get It Done), Don't Behave Like You Live in a Cave, How to Do Homework Without Throwing Up, Get Organized Without Losing It, Bullies Are a Pain in the Brain, 

The Kid's Guide to Becoming the Best You Can Be!  Developing 5 traits you need to achieve your personal best.  

Marythemom:  This was fun because it had activities.  It was part of the basis for the Integrity Study.

Taming Your Gremlin  There is a gremlin within you. He is the narrator in your head.
He tells you who you are, and he defines and interprets your every experience. He wants you to feel bad, and he pursues this loathsome task by means of sophisticated maneuvers: just when you feel you've out-argued or overcome him, he changes his disguise and his strategy. He's the sticky sort -- grapple with him and you become more enmeshed. What he hates is simply being noticed. That's the first step to his taming.
If you have a low tolerance for self-help books or they haven't worked for you, here is a more creative yet practical approach to solving life's problems. Through the powerful metaphor of the gremlin, presented so imaginatively by Richard Carson's writing and Novle Rogers's artwork, you will find ways to identify and banish the tenacious, self-defeating aspects of your personality.
Marythemom:  Great book, but definitely aimed at young adults.  I used it mostly with Bob because she could handle adapting it.  Another one for when she'd gone through every other book I had!

The True Princess  A Parable in the truest sense, this story teaches children the meaning of Jesus' words, "Whoever wants to be great among you must be your servant".
Marythemom:  This book speaks to little girls who want to be princesses - and how to be a TRUE princess.  Beautifully illustrated.

*************************************

Forever Child Series(http://foreverchild.net/)  

The Forever Child: A Tale of Lies and Love

The Forever Child: A Tale of Anger and Fear

The Forever Child: A Tale of Loss and Impossible Dreams

Family Secrets:  A Tale of Silence and Shame

The Forever Child is a series of fairy tales that are designed for use by parents and therapists as a tool to assist children in dealing with early abuse and neglect. Unlike other fairy tales, this series of books illustrates a number of the behaviors that are often seen in children with a history of early trauma, the parent guides provide an analysis of the root causes of these behaviors as well as step-by-step assistance for the parent.

All parents need stories they can share with their children to help generate interest in their backgrounds. Traditionally, foster and adoptive parents have had few choices in children’s tales that are specifically geared towards their child’s early life before adoption. The Forever Child series can meet this need for many families.

It is especially helpful to have the tales read aloud to the child and it is important for parents to read the tale first to determine if it is appropriate for a particular child and situation. Adults who have already shared the tales with their children have reported that they have served as a springboard for many meaningful discussions about birth families and birth history.

THE AUTHORS

Nancy A. Clark, MFT is a retired therapist in the State of California and a seasoned fairy tale writer. She has worked with children suffering from traumatic backgrounds for over 20 years. She was employed as a therapist by one of the largest inner-city school districts in Southern California. Ms. Clark, a foster parent, has four grown daughters and has adopted a daughter with an early exposure to trauma.

B. Bryan Post is an internationally recognized expert in the treatment of adopted children who have experienced trauma and neglect. An adopted child himself he knows firsthand the driving emotions behind the troubling behaviors demonstrated by some adopted children.

Marythemom:  I purchased the first three books.  They are beautifully illustrated paperbacks, but they were a little too specific in some uncomfortable areas and not applicable in others.  I felt these would confuse my kids who are very concrete in their thinking.  I did however have my biodaughter read them to gain some insight and empathy into what the adopted children have been through, and I really liked them for that.  We will not be purchasing the 4th book which is recommended for “MATURE adolescents, teens, and adults.”

Touching Spirit Bear Cole Matthews has been fighting, stealing, and raising hell for years. So his punishment for beating Peter Driscal senseless is harsh. Given a choice between prison and Native American Circle Justice, Cole chooses Circle Justice: He'll spend one year in complete isolation on a remote Alaskan island. In the first days of his banishment, Cole is mauled by a mysterious white bear and nearly dies. Now there's no one left to save Cole, but Cole himself.

Marythemom:  Bear liked this book, but it was a little over his reading level so it took him a loooong time.  If your child is a good reader with anger management issues, especially if, like my kids, they have a Native American background... then you might like this book!

Recommended Books:  

A Safe Place for Caleb: An Interactive Book for Kids, Teens and Adults with Issues of Attachment, Grief, Loss or Early Trauma  A Safe Place for Caleb is a comprehensive and richly illustrated resource for individuals of all ages who are dealing with attachment problems. Parents, professionals, and lay people will find this book helpful in understanding and addressing attachment disorders in children, adolescents, and adults. The first half of the book is an interactive story that follows the experiences of Caleb, a young boy who relates his difficulties and frustrations in forming and sustaining healthy relationships. He learns strategies for coping with attachment issues during his journey to the Safe Tree House, where he is introduced to the four "attachment healing keys". These act as therapeutic tools to unlock difficulties with attachment, and are presented using text and illustrations that are easily accessible for readers of all ages, even for young children. The second half of the book presents a summary of current scientific thought on attachment styles and disorders, and provides a wide array of assessment tools, photocopiable material and healing techniques to address attachment difficulties. Lists of helpful organizations and relevant reading materials are also presented. Based on established psychological principles, the book is a unique and imaginative guide for professionals, parents, caregivers, and people of all ages who are dealing with attachment issues. Marythemom:  I haven't read this one.  It was recommended

Even If I Did Something Awful?    "Would you love me even if I did something awful?"

"If I got orange crayon on the carpet? If I pulled down the dining room curtains? If I told a great big whopper?..."  But what about the "real" calamity? In a reassuring ending, Mommy proves she will always love her little girl, no matter what happens.  Marythemom:  This one was recommended, but I don't own it.

Legal Guardianship documentation

As you know, we're in the process of getting legal guardianship of Kitty, and while her psychiatrist is totally in agreement, and we owe no explanations to anyone else, I've found that currently her school is sabotaging us with Kitty and even making it difficult for Kitty to get services, so I decided to create this document.  (The school has been communicating with DARS which is a program that provides job coaching and help getting employment for adults with disabilities, and have managed to convince DARS that Kitty is "doing great" to the extent that DARS is now requiring an unnecessary new psych eval to reconcile what the school is saying with what we're saying -- and all the documentation shows).

Plus, when it comes time for Kitty's psychiatrist to fill out the form, I want her to have a handy reference for the information she might not have readily available.  Then too when it comes time for us to stand before the judge, I want to be able to give well-documented, concise, unemotional responses, and not get flustered and say something like "She just can't, because I said so!" and look like the over-protective, emotional mama that the school is portraying me as! (My current nightmare!)

The first section is Kitty's current diagnoses, issues and medications.  The orange section are the legal criteria for legal guardianship.  A judge will determine which of these rights should be removed (all, some or none),  Guardianship can be granted for only the financial part, or for the "body," or both.  We believe Kitty needs both.

The last section of this post is using information from the Ansell-Casey Life Skills Assessment which is a VERY comprehensive assessment for foster children aging out of the system.  A lot of this assesses the part of Kitty's life that the school doesn't see, and I believe they make a lot of assumptions about how Kitty deals with life based on the small part of her life she does let them see.

Legal Guardianship

Diagnoses: (04/17/12) -Residential Treatment
Axis I:  309.81  Posttraumatic Stress Disorder, Chronic, by history
296.80  Bipolar Disorder NOS, by history
314.01  Attention-Deficit/Hyperactivity Disorder, Combined Type, by history
294.9    Cognitive Disorder NOS (deficits in processing speed, working memory, executive functioning, and visual memory) - Cerebral Dysrhythmia (TBI) – right temporal lobe. - which controls memory, hearing, understanding language (receptive language), organization, and sequencing.
995.54  Physical Abuse of Child, Victim, by history
995.53  Sexual Abuse of Child, Victim, by history
995.52  Neglect of Child, Victim, by history
307.6    Enuresis, by history
Axis II:  799.99  Diagnosis Deferred (R/O Borderline Personality Disorder - Emerging)
Axis III:         Obesity
327.3   Circadian Rhythm Sleep Disorder (diagnosed 4/13)
        564.0    Constipation
       Acne
               Esophoria – an inward deviation of the eyes, particularly when tired (diagnosed 5/12)
Axis IV:      Problems with primary support group
     Social Environment
     Educational
Axis V:  GAF = 35-40 (current)
Mental Status Examination:
Mood: Stable| Thought Processes:Goal Directed |Judgment:Significantly Impaired |Insight: Poor
H’s Emotional/ Social Developmental Age set at approximately 6 years.
Previously diagnosed with Attachment Issues and 313.89 Reactive Attachment Disorder of Infancy or Early Childhood - not completely resolved.
11/16/2011 Neuropsych -
Full Scale IQ -             74 (4th %ile – Well Below Average), 
Verbal Comprehension –           87 (19th %ile – Below Average)
Perceptual Reasoning –             90 (25 %ile – Average)
Working Memory –            71 (3rd %ile – Well Below Average)
Processing Speed –            65 (1st %ile – Lower Extreme Range)  
7/26/12 Tested for Central Auditory Processing Disorder -scored within normal limits (better than 2 standard deviations below average for an adult - anyone > 12 years of age) on 9 of the 11 MAPA subtests administered. She scored below (worse than) -2 SD on the Tap Test and SINCA (right ear) tests.  She is considered at risk for CAPD, but does not have it.  - All information must be presented shortly, simply and concretely in a calm, quiet, environment for Kitty to have maximum comprehension.  Kitty’s ability to handle stressful situations is low, particularly when aggravated by loud, chaotic environment, and she shuts down when overwhelmed.
8/20/09 – 9/5/09  Neuropsych results from residential treatment center
P300 is absent.  (Means she has ADHD).
Cerebral dysrhythmia (brain damage/injury) in right temporal lobe.  {Temporal lobe controls your:
Memory, Hearing, Organization and sequencing, Understanding language (receptive language).
Temporal lobe disorders: Exaggeration of emotions is sometimes seen with disorders of the temporal lobes.  Deep in the temporal lobes is the “limbic system,” a primitive system involved with emotions and memory (and to some extent sexuality).  Disorders here can turn anger into rage, sadness into suicidal depression, or anxiety into panic.  Electrical disorders in this area can result in atypical psychotic symptoms, inappropriate sexual behavior, and unusual fears.  Memory problems are common.  Temporal lobe patients are prone to “bad days” when their behavior is out of character.  They are unpredictable and may become depressed or explosive without provocation.
Right hemisphere disorders:The right hemisphere is important in visual spatial reasoning, visual memory, and organizational ability and pattern perception.  In addition, the right hemisphere is involved in the non-verbal aspects of communication such as facial expression, body language, gestures, and voice inflections.  Individuals who cannot express or comprehend such non verbal signals are at a social disadvantage.  Even with normal language, their lack of non-verbal signals makes their communication dull and ineffective.  If they cannot see patterns of social relationships or communicate effectively they may seem odd and be rejected by peers, resulting in problems that peak in adolescence.  Visual processing problems can produce learning impairments which impair schoolwork in math, science, and other visually learning classes. ~From Neuropsychiatry by Dan Matthew, M.D and Larry Fisher, Ph.D.

Current Psychotropic Meds:  Trileptal 1800mg (mood stabilizer), Seroquel XR 400mg (atypical antipsychotic), Wellbutrin XL 300mg, Lamictal 250 mg (mood stabilizer), Intuniv 4mg (regulator for ADHD), Ambien 10mg (PRN sleep med), Loratadine 10mg (allergies).


Disclaimer thrown in for Kitty's school and the DARS caseworker that will be removed before this is given to the psychiatrist:
I will readily admit that MOST teenagers do not meet the criteria for being able to live independently; however, we feel, and Kitty’s psychiatric evaluations show, that Kitty ‘s severe deficits/issues  in cognitive, judgment, insight and coping skills – due to her disabilities – including brain injury, mental health disorders, severe trauma and relational issues – are not showing meaningful improvement.  Our goal is to support Kitty while she reaches her full potential.

Criteria for Legal Guardianship:

 YES  NO [X]   1. Ability to make informed judgment as to marriage 
While we would love for Kitty to be happily married, and of course would take her wishes into consideration, we would need to be assured that Kitty’s potential spouse could handle her medical needs from her permanent brain damage and other diagnoses, is capable of handling her many appointments, finances, and accessing and handling her many needed government benefits and services.  Kitty has a very limited understanding of what to look for in an appropriate spouse, and has severe unresolved relational issues (313.89 Reactive Attachment Disorder of Infancy or Early Childhood and 799.99 Borderline Personality Disorder).  She is very vulnerable, and often a victim, her issues with boundaries and judgment leave her open to being taken advantage of by predators or others not looking out for her best interest.  

 NO YES  2. Ability to make informed judgment as to voting 
I have no opinion on this one.  Kitty is more likely to care about voting Team Jacob than for the president.  I think she would choose whomever her friends like, unless one president is cute.  In that respect she’s not much different than most of America.

 YES  NO [X]   3. Ability to apply for and receive governmental benefits 
This requires a level of planning beyond Kitty’s capabilities.  She requires the assistance of a trusted, qualified supervisor to access and manage her governmental benefits and services and prevent lapses in services.  She refuses to read documents and will sign anything she is asked to without comprehension of the contents.  She does have limited comprehension if the document’s contents are broken down into short, simple and concrete information, which is then given to her verbally.

 YES  NO [X]   4. Ability to operate a motor vehicle 
The following are a few of the actual questions on the Texas driver’s license application:
• Do you currently have or have you ever been diagnosed with or treated for any medical condition that may affect your ability to safely operate a motor vehicle?  
Esophoria (eye disorder causing dizziness and double vision), 
Chronic Sleep issues – Circadian Rhythm Disorder - causing general inability to focus, sleepiness, dizziness, and inability to process.  
Cognitive Disorder NOS – Permanent brain injury that severely affects her judgment and processing (processing issues – if under stress or feels she is in loud or chaotic conditions, her processing ability drops to 65 (intellectually disabled).  Includes an inability to multi-task.
ADHD – inability to focus.  
• Within the past two years, have you been diagnosed with, been hospitalized for or are you now receiving treatment for a psychiatric disorder?  
YES!  See page 1 of this document for diagnoses.  Recent psychiatric hospitalizations: 3/11, 4/11, 8/11, 10/11, 11/11, 12/11.  Recent psychiatric residential treatment 12/11 to 4/12.  Currently under care of a psychiatrist and multiple therapists.
• Do you have any alcohol or drug dependencies that may affect your ability to safely operate a motor vehicle or have you had any episodes of alcohol or drug abuse within the past two years?  
The majority of her medications have severe contraindications to operating a motor vehicle (cause sleepiness, dizziness, impaired judgment…).  She has frequently made mistakes in taking (or missing) her medications that would cause additional severe issues with safely operating a motor vehicle.

YES  NO [X]   5. Ability to make decisions regarding travel 
Requires qualified supervision to maintain her medical and emotional needs.  Skills needed that she does not currently have:  medication management and obtaining appropriate health care, judgment regarding where/when it is safe to go and with whom, obtaining a hotel room, financial budgeting/ management  – including purchasing tickets and food, ability to read and follow a map or timetable, feeling safe on a plane, train or bus...  

YES  NO [X]   6.  Ability to seek or retain employment  
With a lot of support, I believe Kitty could seek, obtain and keep a part-time job.  She will need assistance with job hunting and finding an employer willing to accommodate her special needs, including an inability to work early morning hours due to her sleep disorder.  She has limited understanding of her issues and how they may affect her ability to handle herself safely on the jobsite.  She will need limited hours, particularly if the environment is demanding or chaotic in any way.  She has not been able to demonstrate the ability to cope with the demands of employment for more than brief periods of time.

 YES  NO [X]     7. Ability to contract and incur obligation 
Kitty has a does not comprehend the obligations and effects of a contract.  She has a limited concept of money, debt, budgeting, recordkeeping and finances.  She has NO understanding of credit cards, interest rates or payment plans.  Kitty does not appear to have the ability to plan for the future or the consequences of her actions and makes emotional, impulsive purchases without thought toward future goals or practical needs.  She has little interest in where money to pay for things will come from, instead focuses on purely emotional justification for purchases.  

 YES  NO [X]   8. Ability to sue or defend lawsuits 
Kitty has a concrete, black and white sense of right and wrong, primarily based on how it affects her.  She has a severely limited ability comprehend complex legal documents or concepts (see #3) or understand the full consequences of her actions.

 YES  NO [X]   9. Ability to manage property or to make any gifts or disposition of property 
The level of planning required to manage property or make decisions regarding financial dispensations is beyond Kitty’s capabilities.  

 YES  NO [X]   10. Ability to determine residence 
While we will certainly take Kitty’s wishes into consideration, we would need to be assured that Kitty’s future residence could handle her medical needs from her permanent brain damage and other diagnoses is able to get her to and from work and her many appointments, and can provide constant support and guidance - including frequent prompts and direction, regarding basic self care, emotional regulation, common daily living activities and emergencies OR that Kitty lives close enough to her family that we can provide those services that the place of residence cannot or will not (such as transportation to appointments or shopping, financial services…).   At this time, Kitty does not have the ability to contract with someone and ensure they receive payment for services rendered.

 YES  NO [X]   11. Ability to consent to medical, dental, psychological, and psychiatric treatment and to the disclosure of those records 
Kitty does not have a good understanding of her diagnoses, medications or treatments.  She exhibits great difficulty understanding, evaluating, and tracking her medication and its side effects, the efficacy of different treatments, and even her own needs.  She demonstrates limited comprehension regarding her health and mental health issues, even exhibiting strong denial/refusal of medically-determined needed treatment.  She has strong psychosomatic issues and low body awareness.  She is generally compliant with taking her psychotropic medication (with multiple reminders), but refuses to take anything but pills, so is not in compliance with her prescribed nasal sprays and other types of meds.  

YES  NO [X]   12. Ability to handle a bank account 
Due to her cognitive issues, Kitty has a very limited understanding of money or budgeting. She requires extensive support in all financial matters. 

YES  NO [X]   13. Ability to make decisions regarding financial obligation 
Due to her cognitive issues, Kitty has a very limited understanding of money or budgeting. She requires extensive support in all financial matters. 

 YES  NO [X]   14. Ability to enter into insurance contract of every nature 
This requires a level of planning beyond Kitty’s capabilities.  She requires the assistance of a trusted, qualified supervisor to access and manage her financial and contractual concerns.  She does have limited comprehension if the document’s contents are broken down into short, simple and concrete information, which is then given to her verbally BUT would be unable to ensure the contract was enforced.

****************************************************** 

Life Skills:

1. Motivation for personal goals: initiative, engagement, willingness to try new things, persistence, work ethic, commitment, and a drive to pursue interests and personal development.
Kitty is very compliant and will set to any task assigned by those from whom she masks her issues (generally everyone but family).  This need to please and mask her issues often leads to overwhelming, incapacitating feelings triggering shutdowns, rages, and/or suicidal ideation.  Kitty requires both constant and extensive emotional support from people knowledgeable about her diagnoses and trained in meeting her needs, and a calm, contained, controlled environment in order to help her maintain the level of emotional stability needed to keep her from requiring frequent psychiatric hospitalizations and/or residential treatment.  While Kitty’s dissociation from reality has improved over the last few years, she still has great difficulty grasping the duties and responsibilities necessary to establish and achieve her goals while maintaining her health and safety.

2. Executive functioning skills: planning ahead; organization; execution and completion of projects; informed decision-making; judgment; concentration; and self-monitoring.
This is an area strongly affected by Kitty’s brain injury/ cognitive disorder.  She has well-documented, severe issues in all of these areas requiring extensive support.

3. Independent living skills and self-reliance: self-management with regard to:

• money
She has significant difficulty with money and budgeting (no, or limited, understanding of:  the cost of eating out, pre-packaged food, weekly menu planning, inability to calculate discounts and tips…).  Limited understanding of the difference between personal needs and wants.  Able to set saving goals, but unable to stick to them due to impulse purchasing.  No interest in reading documents, maintaining records and keeping track of her finances  Easily influenced by advertising.  Unable to identify, access and utilize programs and services for assistance.
She has great difficulty with memory and forgets how much she has, what she owes and why, and for what she wants to save her money.  She talks of expensive trips and items, with no concept or interest in acquiring them herself, but instead assumes someone will give them to her.  She has no understanding of budgeting.  She refuses to keep records.  Although she does have some understanding of comparison shopping (as long as it’s in the same area of the store), coupons, and sales – it’s all relative.  She can identify the less expensive pair of shoes, but has great difficulty with impulse buying and emotional purchasing.  If she wants new shoes she buys them, she doesn’t think about future consequences (for example, not having enough money to buy bread or pay her water bill).  She has a severely limited ability to save money (requiring a lot of support and reminders).  She has stated she has NO interest in working hard to acquire money.
She has serious issues with math (ex.  Kitty has asked me how much a pair of $10 shoes would be that were marked 50% off.  Knowing the date, December 21st, she asked me how many days it was until Christmas and still couldn’t figure it out even after I told her Christmas was December 25th.  She does well in special education and modified math at school, but has limited ability for practical applications).  She has had a checking account for 2 years, but is not able to use it and relies on us to tell her if she has enough money to make a purchase, remind her of things she wanted to save money for, and then say yes or no regarding impulse purchases, knowing she can’t control the impulse and will be upset later.

• nutrition – 
Kitty can cook with supervision.  She does not understand the need for moderation or  making healthy, nutritious dietary choices (skips meals, emotionally eats, chooses to eat foods to which she has allergies/ intolerances, limited to no understanding of serving sizes, gorges on snacks and sweets…).  Appears to have limited to no food safety and food handling skills (manual dexterity issues, will leave food at room temperature for hours, doesn’t understand the dangers of working with raw meat, stores food uncovered for extended periods of time…).  She is oblivious to the big messes she makes, and even when prompted, frequently refuses to clean after herself.  She has made dangerous mistakes with the microwave and stove.  She has difficulty reading and following recipes (skips steps, ignores words she doesn’t know, makes measuring mistakes…), difficulty reading nutrition labels and ingredients….

• laundry; -
Kitty is capable of handling her clothes with minimal supervision, but needs reminders to pick up dirty laundry, wash her clothing, and put it away.  She needs consistent reminders and redirection to wash bed linens and towels or she will not do so.  After a reminder to clean her room (covered in used clothing, sanitary napkins, tissues…), she will throw everything in her laundry basked and has washed shoes, books, sanitary napkins, rewashed clean clothes, dry clean only items, electronics…  She requires frequent reminders of what clothing is appropriate for the weather and occasion, and does not notice stains, holes or odors.  Often she will discard out of season clothing, or clothing she no longer likes, without thought of replacement.

• independent living –
She lacks many of the basic skills needed to ensure health and safety, including food prep, medication management, laundry, shopping, cleaning and maintenance of the home…  She will also need assistance managing her estate/ finances.
Kitty is capable of doing simplified, basic chores, with frequent reminders and redirection; these are age-appropriate for her developmental age of 6.  (see attached Chore Chart and Level System – we discontinued the level system because she was stuck at Level 1 and it was damaging her self esteem).  She cannot multi-task so these chores must be broken down into incremental steps and given to her in small doses with multiple breaks.  Will not independently do needed cleaning not on her chore list (ex.  Picks up dirty dishes – her chore - but leaves them near the sink full of napkins and other trash and/or rotting food).  Several chores (washing dishes, vacuuming, mopping… have consistently triggered an emotional trauma response to the point that these chores are no longer assigned).

• self care and hygiene
Kitty requires frequent reminders to bathe and brush her teeth, use deodorant, dispose of personal hygiene products properly, keep track of personal items, and get enough sleep -- She has circadian rhythm disorder, which means she has a difficult time getting a full eight hours sleep due to an inability to fall asleep at a reasonable hour and stay asleep throughout the night.  Sleep medications are ineffective.
Kitty has high psychosomatic issues, but very little awareness of her physical body (hunger/ satiation, constipation, tiredness, tension…) this has improved greatly with somatic therapy (she now has awareness of things like food on her face and can feel now feel touches on her extremities, including physical pain, when her extremities are injured.
She refuses to comply with the medications and treatments for her severe issues with constipation, acne, and allergies and generally refuses prevention measures for these and other issues such as chronic ear infections and compacted ear wax (causing hearing loss) and frequent urinary tract infections.
Kitty requires an adult to make appointments and ensure attendance at appointments for doctor/ dentist/ psychiatrist/ specialists/ therapist… Kitty has limited to no knowledge of personal and family health history.  She requires others to maintain up to date medical records including current medications and diagnoses.
Ex.  When Kitty was tired of being poked and prodded at the beginning of the summer for some very serious health issues, she began refusing treatment and denied she even needed them.  Conversely, she frequently demands appointments for minor or psychosomatic issues.
She has no interest or ability in maintaining her complex medications (including filling med box, taking them in a timely manner, side-effects, awareness of what she takes and why…)

• time management
Kitty is unable to set or awaken to an alarm clock.  She requires multiple verbal prompts to awaken.  She has little sense of time and does best with multiple prior notices of transitions and changes.  She is unable to read a non-digital clock.

• personal safety
Kitty has consistently demonstrated an inability to acknowledge and handle minor household emergencies, such as hazardous spills, overflowing toilets (common occurrence due to her chronic constipation) or appliances malfunctioning. She doesn’t notice the problem, refuses to handle the problem (such as breaking something glass and refusing to clean it up without significant pressure from an authority figure), and/or she panics.  We have not assessed her on fire safety (such as the use and maintenance of a fire extinguisher or avoiding overuse of extension cords) or home safety (such as proper storage of cleaning supplies).  She frequently shows reckless disregard to personal safety, computer and internet safety, and prevention of breaking and entering into the home.
• medication and health care
Kitty requires constant supervision and direction in taking her medication.  She requires verbal instructions, with reminders, when taking new medications (cannot interpret instructions provided on prescription drugs and over-the-counter medications, including dose frequency, contraindications, warnings, recommended storage (e.g., safety cap use) and possible side effects).  While she is generally very compliant with taking most (but not all) of her medication, she has no interest or ability in filling and maintaining her med box or learning about her meds and their side effects.
She requires adult direction in treating minor issues such as pain, cold/allergy,stomach upset or diarrhea… and in first aid beyond a bandaid. Requires assistance in determining if something beyond first aide is needed.
• public transportation
Kitty has never used public transport.  We do not live in an area that provides it.
• job experience (with job application, interviewing, working hard, accepting criticism and following directions).
See previous notes.  Limited to no skills in filling out a job application (She does not understand a lot of the words/ concepts on the application, and standardized testing shows she reads and comprehends well below grade level; she writes at about a 3rd grade level.  She has few skills and even less interest in researching and obtaining services, refuses to fill out applications and has little to no memory of the information needed to accurately complete the forms).  Dedicated, hard worker, who works best with clear directions.  Frequently assumes criticism is implied even when it’s not.  Finds work very stressful and draining.  Acknowledges that she will need a job with a late start due to her sleep issues.  Currently receives vocational support, including a job coach.

4. Academic skills: basic skills to achieve age-appropriate educational goals; intellectual curiosity; study habits; and value on learning.
Kitty is being told that she has the skills needed to go to junior college.  Little to no evidence has been produced that she can register and determine what classes she needs, sit in a classroom of more than 8 people, listen to a lecture and take notes, read a textbook and summarize what’s relevant, do more than 20 minutes of homework, write a research paper…

• Kitty cannot take effective notes, does not study independently, and currently takes only modified tests in a small group environment.
• Kitty could get to class with assistance, prompts, and reminders.  Kitty has consistently shown an inability to work on and complete multistep long term projects
• Kitty has no, or limited, note taking skills due to her inability to summarize and take what is important from written and verbal communication. Tasks must be broken down for her.
• Kitty must have modified testing, and writes and spells on about a third grade level.  Kitty has limited writing abilities beyond the concrete; she consistently demonstrates an inability to write using abstract concepts.

5. Physical fitness and healthful habits: value and self-care in relation to exercise, sleep, eating, health maintenance, and limitations on risk taking, substance use and media overuse.
Kitty requires frequent reminders and assistance in: regulating her food intake (she’ll gorge on sweets and junk food), overuse of media, going to bed and getting up (She is under a doctor’s care for her severe issues with sleep).  Kitty will occasionally walk in the backyard or in the neighborhood with a friend, but otherwise refuses any exercise (although she is compliant with an exercise program at school).

6. Emotional awareness, reflection and regulation: recognition and appropriate expression of feelings; empathy for others; ability to control impulses; and coping with negative emotions.
Kitty’s issues with emotional awareness is very linked to her somatic issues and she has made equal progress, but she still has severe issues with insight, emotional regulation, judgment, impulse control… Her problems with suicidal ideation and self-harming are currently under control after a med change and with reduction in stress levels. She is able to ask for and accept help.
Stress - Kitty is at close to max capacity for stress while remaining stable and able to have emotional regulation in public.  She has almost nothing left when she gets home.  Her home life has been modified, structured and regulated to reduce her stress level, giving her as much flexibility as possible to handle her public behavior.  She would literally rather die than let non-family, friends and professionals, see her as anything less than perfect.
Kitty has difficulty correctly identifying:

• situations which may cause conflict between people and lead to stress.
• sources of conflict or fear in a stressful situation.
• strategies to reduce stress and maintain good emotional health (e.g., exercise, deep breathing, simplify schedule, journal).
• signs and symptoms of depression and other emotional health problems. 

She has learned strategies to reduce stress  (e.g., exercise, deep breathing, neurofeedback techniques…), but is unable to access these techniques when under stress or feeling strong emotion.  
Empathy - Kitty has shown increasing empathy for others, but is still severely limited in this area.  Improvements might be more about hyper-vigilant concerns for her own safety and needs than an actual concern for others’ feelings. 
Insight – Kitty’s lack of insight, combined with her inability to process Dialectical Behavior Therapy strategies, caused her removal from psychiatric residential treatment.  

7. Social skills: ability to size up interpersonal situations; cooperation with others; communication skills; conflict resolution skills; gaining perspective; and accurate self-appraisal in groups.
Kitty behaves appropriately in public and gives the appearance of adequate social skills, but they are immature for her chronological age.  Kitty’s emotional/social development is significantly delayed (between 6 and 10 years of age).  She has very little personal insight and often sets inappropriate boundaries.  Her social skills have improved in the last few years; although her world is still very black and white, she is more tolerant of others breaking the rules than she has been in the past.  She is learning to accept that faults in others, including what she perceives as their mistreatment of her, does not mean the relationship has to end.
Kitty is very easily influenced by her peers and struggles with cognitive distortions.  While she will often strongly stand by her convictions, even if presented with rational evidence that she has made an error in thinking, at other times she will completely change her position to reflect the views of whatever individual or group with which she wants to assimilate.  (E.g. While in residential treatment, Kitty, who prior to this had been strongly Christian, suddenly became Wiccan, like her new roommate.  When the roommate graduated the treatment program, Kitty went back to being super Christian, without ever noticing how easily influenced she was by her peer).  Our concern regarding relationships is that Kitty is easily convinced that a boy cares about her, and if the boy can get past her sexual abuse issues and convince her to sleep with him, and then she’ll want to keep any resulting baby – despite having NO  realistic way to support it. She believes events will ensue, behaviors change instantly or things materialize because she wills it, rather than focusing on working a plan, learning calming techniques or behavior management, or earning and saving her money.  (Ex.  She’ll say she won’t have another rage/ meltdown, because she “just won’t.”). 
Boundaries – Kitty does not always set appropriate boundaries with peers, particularly involving teasing and personal space.  She frequently initiates a teasing relationship and then allows others to increasingly tease (physical and emotional) until it reaches the point of being inappropriate.  She requires adult intervention to reset more appropriate boundaries.  

8. Relationship skills and values: ability to maintain relationships over time; friendship development; conversational ability; balancing needs of self and other in romantic relationships; and intimacy skills.
Kitty has strong verbal skills and can hold an appropriate conversation on topics in which she has an interest.  She makes friends easily, but has difficulty maintaining friendships.  She has difficulty with boundaries and is very easily influenced by peers, because she desperately wants to fit in and be accepted.  Due to her attachment disorder and emerging borderline personality disorder, Kitty greatly struggles with her intimate relationships especially long term.
  
9. Moral behavior, integrity and character: standing up for what’s right; conscientiousness; and responsibility for oneself and the less fortunate.
Kitty has strong beliefs and character and is willing to fight for what’s right; however, she can be VERY easily influenced by peers, especially when it validates or reinforces her RAD issues with family.

10. Spirituality and a purposeful life: ability to accept and cope with adversities; emotional resilience; drive for a meaningful life; and a value on reflection and growth over time.
Kitty has very little emotional resilience and insight,  She tends to focus on the negatives, and will distort reality to match this perception, including having extreme dissociation and completely blocking the memories of an event.  She is very reactive to situation and in the moment rather than planning ahead or dealing with the past.