Josh is a 7-year-old boy who has been living with his aunt, Helen, for the past five months. Helen is seeking custody of Josh as she is committed to providing him with a stable and supportive home. However, Josh's behaviours are escalating, and Helen is finding it increasingly difficult to care for him on her own. Josh has been asking Helen if he will be able to stay with her forever, which indicates his need for a secure attachment.
Josh has experienced multiple changes in living arrangements and has been moved between various relatives and family friends since he was 2 years old. He was removed from his parents' care at age 2 and returned to them when he was 3, but he was removed again one year ago. During his early years, Josh was exposed to chaotic and violent environments. He was born while his mother was in a transition home, and shortly after, his parents reunited for a period of time. However, his father disappeared, so contact has been lost. Josh has not seen his mother for the past year, and while in her care, she frequently moved around and had many different men in the homes.
There is a query of Fetal Alcohol Spectrum Disorder (FASD) and many symptoms of Attention Deficit Hyperactivity Disorder (ADHD), but no formal diagnosis has been made.
Josh can be engaging and friendly when he feels comfortable with someone. He enjoys talking and has a good sense of humour. He does well with art activities like colouring and painting and has a lot of energy. Josh loves climbing on playground equipment and enjoys helping younger children. He gets along well with his younger cousins.
Josh tends to be clingy with Helen and does not want to leave her side. He asks repeatedly about how long he will be allowed to live with her, which indicates his need for stability and reassurance. When his needs are not met, or things do not go according to plan, Josh can become explosive, which can last for hours. During these meltdowns, he yells, swears, throws things, and can destroy things around him. He has locked himself in the bathroom when he was triggered by something, and it was difficult to get him to come out. Josh gets extremely angry and can be aggressive when he is upset.
Josh becomes overwhelmed by noise and busyness, such as the school bell. He appears tired and on high alert when he comes to school. He has difficulty sleeping and experiences night terrors. He can often be found twisting his hair and rocking back and forth. When he is stressed, he sucks his thumb. Josh is hungry all the time and takes food from others at school.
Josh has difficulty making friends with his peers as he can be bossy and intimidating. He tends to push others around physically and emotionally and makes sure he is first in line. Students in his class do not seem to like him.
At school, Josh is often disruptive and easily frustrated. He is defiant and refuses to complete tasks, especially with substitute teachers. He loses his school books and has difficulty organising his desk. Although he appears to have good expressive language, he does not seem to fully understand what is being asked of him and is often a few steps behind the class in completing tasks. Josh is self-critical and calls himself dumb and compares himself to others.
Josh has been diagnosed with ADHD and Oppositional Defiant Disorder (ODD). The social worker has expressed concern that Josh may also have FASD. He has recently been prescribed Ritalin, but this has not had a significant impact on his behaviour. Helen tried using a consequence-based behavioural.
Given Josh's history of complex trauma, we tried several different therapeutic approaches, including:
Trauma-focused cognitive-behavioral therapy (TF-CBT): This evidence-based therapy is specifically designed to help individuals who have experienced trauma. TF-CBT typically includes a combination of techniques, such as cognitive restructuring, exposure therapy, and relaxation training. The therapy can help Josh to develop coping strategies, improve his self-esteem, and address negative beliefs and thoughts that stem from his trauma. Additionally, it can help Josh manage his behaviour and emotions.
Eye movement desensitisation and reprocessing (EMDR): EMDR is a trauma therapy that involves being guided to recall traumatic events while performing eye movements, auditory or tactile stimulation. This therapy helps to process traumatic memories and associated emotions, and to develop a more adaptive understanding of experiences. EMDR may be particularly helpful in addressing nightmares and other symptoms of post-traumatic stress disorder (PTSD).
Attachment-based therapies: Given Josh's history of disrupted attachments, attachment-based therapies such as Dyadic Developmental Psychotherapy (DDP) and Theraplay may be helpful. These approaches focus on building secure attachments and developing trust with caregivers, which can help to feel more safe and secure. Additionally, these therapies can help develop emotional regulation skills and improve his capacity for self-reflection.
Sensorimotor psychotherapy: This approach emphasises the connection between the body and mind and aims to help individuals heal from trauma by addressing the physical sensations associated with traumatic memories. Sensorimotor psychotherapy may be particularly helpful for experience of overwhelming emotions and physical symptoms like stomach aches and headaches.
After several months of trauma-focused therapy, Josh made significant progress in managing his emotions and behaviour. He was able to develop a stronger sense of trust in his aunt and their relationship, and he no longer had the same level of clinginess or fear of abandonment.
Josh's attachment experiences with his aunt became more secure, and he was able to regulate his emotions more effectively. His meltdowns became less frequent and less intense, and he learned new coping skills to manage his feelings of overwhelm and anxiety.
At school, Josh became less disruptive and more engaged in his learning. His teachers reported that he was able to follow instructions better and complete tasks more independently. He also began to make friends and form positive relationships with his peers.
Overall, Josh's progress in therapy has been significant and promising. He still faces challenges, but he now has a greater sense of resilience and self-awareness to help him navigate his ongoing journey of healing from complex trauma.