SSP Associate: Rosie Mann, RN
Name of Organization: Forged in Fire
Client and age: AC, 13 years and 1 month
Clinical history before SSP
AC was exposed to marijuana and alcohol in utero, possibly other substances as well. She entered foster care at birth and was adopted at two years of age by her foster mother. AC was sexually abused multiple times by a family member and experienced the death of a sister. Her adoptive mother is a single mother of 12 children, biological and adopted. AC had other foster children in and out of the home while she was young. She was diagnosed with post-traumatic stress disorder as well as oppositional defiant disorder. She has never taken any medications.
AC has always been homeschooled because that was the preference of the adoptive mom, who had homeschooled all of her other children. Mom was having difficulty with schooling because AC’s attention span was very short and she would experience significant frustration at the slightest challenge. Frustration looked like throwing and tearing papers and walking away. AC would elope on a daily basis for hours at a time. Mom would not know where she was, what she was doing, or whom she was with. Sleep was also an issue, with AC waking up almost nightly and going downstairs to watch TV.
At the time of the referral for the SSP in June 2019, AC was struggling to attend summer camp. She was aggressive and argumentative with staff and other campers. Mom was not sure she would be able to continue to attend camp. AC was also attending appointments with a play therapist but was unable to engage. She would either sit on the sofa and suck her thumb and hold a blanket, throw things around the room or run out. The therapist referred AC for SSP to down-regulate her stress response so she could effectively engage in therapy and to aid in the management of the elopement. Consideration was being given to admitting AC into a partial hospitalization program.
Prior to beginning the SSP, AC and Mom completed Strengths and Difficulties Questionnaires, and AC completed Multi-dimensional Assessment of Interoceptive Awareness. Mom’s results for the SDQ indicated:
- Emotional problems – very high
- Conduct problems – very high
- Hyperactivity – very high
- Peer problems – high
- Prosocial skills – slightly low
- Overall difficulties score – 21 (very high)
AC’s results for the SDQ indicated
- Emotional problems – close to average
- Conduct problems – very high
- Hyperactivity – high
- Peer problems – high
- Prosocial skills – close to average
- Overall difficulties score – 10 (close to average)
AC’s results for the MAIA indicated a very low score on the awareness of connection between body sensations and emotional states, the ability to regulate distress by attention to body sensations, the ability to listen to the body for insight, and the ability to experience one’s body as safe and trustworthy.
AC’s insights into her own challenges and how her internal state plays a role in her regulation were very poor.
Implementation of the SSP
The SSP was planned with goals of:
- Reduce and or eliminate eloping
- Reduce stress response (throwing, yelling, running out) during therapy sessions
- Increase ability to focus and attend to school work
- Prevent need for partial hospitalization program
I began seeing AC in her home on June 29, 2019. During my first two visits with AC and her mom, AC would sit nearby and suck her thumb and hold her blanket. She would not speak to me and had very little eye contact. She initially accepted the headphones and music for about five to 10 minutes, then would become dysregulated and run out of the room. After two daily attempts to increase tolerance for the headphones and the music, I tried to administer the music through speakers. AC took the speakers and threw them. I decided to attempt to administer day 3 to try and get some regulation into her system so she could tolerate the music. On July 3, I administered day 3 through speakers while following AC. She was dysregulated so we walked together. She tolerated 30 minutes of day 3.
The next day I once again offered the headphones, which she tolerated. She listened to 30 minutes of day 1. Following the 30-minute session, she became extremely dysregulated and eloped from her home. She returned after about 30 minutes and was experiencing a severe increase in itching from her chronic eczema. I decided to move to an every-other-day schedule.
- On July 6, administered 30 minutes of day 2 with speakers
- On July 8, administered 30 minutes of day 2 with speakers
- On July 10, administered 30 minutes of day 3 with speakers
- On July 12, administered 30 minutes of day 3 with speakers
We would walk outside while listening or AC would want to be under a blanket with her head covered and not be near anyone while listening.
After administration of the second 30 minutes of day 3, AC became extremely aggressive with me each time I visited. Each time I visited twice weekly, she threw books, pillows, boxes, clothing and bottles. She also dowsed me with water, dish detergent and lotion. She pushed and slapped me, leaving bruises, and often locked herself in her room. She on one occasion threatened me with a knife, on another occasion with an ax. She would take my keys and phone and hide them in attempts to control me. She would sit in my car and refuse to get out. She threw candy at my car. She did not show this same aggression with her mom; however, she did continue to elope. Due to the increase in aggressive behaviors, I stopped delivery of the SSP.
My focus was on being a calm, safe and unwavering presence for AC. I continued to come twice weekly and let her know that none of her behaviors frightened me. I was going to continue to come back no matter what she did. I worked with her mom on how to affirm and attune to AC’s state and how to parent with empathy and connection. I worked with mom on, when AC returned after eloping, having a meal and drink waiting for her. We also worked with mom on how to tell AC how frightened she was when she could not keep her safe because she ran away. I worked with Mom on how to let AC know that she was there to take care of her and understand her feelings. We worked diligently on changing Mom’s parenting strategies to those of connection instead of punishment. I also worked with Mom on her own neurological state so that she could be the calm, safe presence for AC just as I was modeling for her. Mom worked diligently and was consistent in her empathy and connection, which I believe was a major contributor to the success of the SSP.
I also worked with AC on interoceptive skills. She would often state she felt nothing in her body. We began work on interoceptive skills by focusing on what she felt when she was in a calm state. We slowly worked up to bringing her attention to her dysregulated internal state and relating that to her emotions and behaviors.
We also engaged in rhythmic, repetitive, relational activities during each of my visits. These activities were designed to bring regulation to her lower brain. We rode bikes, walked, went to the playground, painted on large paper and did stretching exercises. I also worked with her on HeartMath as a means of building interoception and regulation skills and taught Mom how to do MNRI repatterning exercises for fear paralysis, moro, and foot and core tendon guard reflexes.
During this time, AC was not able to attend camp nor continue with therapy sessions due to the severity of her dysregulation. Contact was maintained with the treating therapist during this time.
The SSP was repeated in November 2019.
Response to SSP
I continued visits twice weekly until October. During that time, elopements decreased steadily.
In October, three months post-SSP, the SDQs were repeated by both AC and her mom, along with the MAIA by AC. Mom’s scores indicated an overall improvement in every subcategory and overall difficulties score going from 21 (very high) to 13 (close to average): Emotional problems seeing a reduction from a score of 7 to 5.
Post-SSP
- Conduct problems – reduction from a score of 7 to 6
- Hyperactivity – reduction from a score of 10 to 8
- Peer problems – reduction from a score of 4 to 2
- Prosocial skills – increase from a score of 7 to 8
Mom described feeling like she had her daughter back. Mom stated that the empathetic connected way of parenting made a profound impact on both herself and her daughter. They had a renewed relationship.
AC’s scores indicated an overall improvement in conduct, hyperactivity, and peer problem scores. Emotional problems and prosocial skills scores remained unchanged.
- Overall difficulties score improved from a score of 10 to a score of 1
- Emotional problems – unchanged score of 2
- Conduct problems – reduction from a score of 7 to 5
- Hyperactivitiy – reduction from a score of 10 to 3
- Peer problems – reduction from a score of 4 to 1
- Prosocial skills – unchanged score of 10
Scores on AC’s MAIA revealed a minor increase in awareness of connection of bodily sensations and emotional state and experiencing one’s body as safe and trustworthy. Scores also revealed improvement in the ability to regulate distress by attention to body sensations and significant improvement in actively listening to the body for insight.
Mom described feeling like she had her daughter back. Mom stated that the empathetic connected way of parenting made a profound impact on both herself and her daughter. They had a renewed relationship.
With the significant improvements in functioning reported by Mom and the improved scores, the decision was made to repeat the SSP in November 2019 with the hope of achieving the goal of returning to therapy.
The second delivery occurred in November of 2019. This delivery was entirely through headphones. I decided to deliver only 30 minutes of each day for five consecutive days due to the extreme dysregulation following the first delivery. She remained regulated during each session and we colored, painted and played Play-Doh.
AC no longer elopes. She is able to identify dysregulated state and utilize tools to down-regulate. She is now able to label internal states and associate them with emotions. She is now willing to notice body sensations and emotions, though reluctantly, which previously she refused to do. She sleeps through the night, now with their pet dog in her bed for co-regulation. She no longer goes downstairs during the night. She did not require a partial hospitalization program.
AC now welcomes me when I arrive and we engage in games and conversation. She makes eye contact and is socially engaging. She only slaps me impulsively about once a month and recovers quickly from the dysregulation. She has only dysregulated significantly one time with Mom over the past four months. Mom reported being very surprised by the dysregulation because it has not happened for so long. We are working on social thinking and the development of perspective-taking and remorse. She is attentive to school work with her mom and engages in even challenging lessons. She participates successfully in group activities at her church.
We are working on the final goal of returning to therapy so that AC is able to process her past traumatic experiences. To date, she is able to regulate her state in the therapist’s office while playing games with me and Mom.
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