sarahlusardi,msw july24,2013 - collaborative...reactive attachment disorder children with reactive...

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Sarah  Lusardi,  MSW  Alison  Morrisey,  LCSW  

July  24,  2013  

Attachment and the Impact of Trauma

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Objectives Gain a basic understanding of attachment theory and its implications for working with infants and toddlers.

Understand the importance of attachment for early development.

Distinguish between secure and insecure attachments and how the four identified attachment patterns affect infants and toddlers. Understand the importance of protective and risk factors and caregiver responsiveness for the development of resiliency.

Gain familiarity with treatment modalities and local clinical resources for young children and their families.

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A deep and enduring emotional bond that

connects one person to another across time and space. (Ainsworth, 1973; Bowlby,

1969)

Attachment

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Attachment theory did not evolve until1950’s with John BOWLBY and then continued by Mary AINSWORTH in 1960’s and 1970’s.

Attachment Theory

Primary conclusions….

Infants come into the world pre-programmed to form attachments to others because it will help them to survive.

It started how late?!

Attachment is triggered by threat of separation from attachment figure, insecurity or fear.

The most critical time for attachment is between 6 months and two years The attachment figure is a secure base from which the infant can explore the environment

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Basic Components of Attachment

Infants  become  aBached  to  individuals  who  are  sensiEve  and  responsive  to  them  in  social  interacEons  AND,  who  are  a  consistent  caregiver  for  a  significant  Eme  between  six  months  and  two  years.        

Infants  and  toddlers  use  their  aBachment  figure  as  a  secure  base  from  which  to  explore  their  environment.  

Caregiver’s  responsiveness  to  the  infant/toddler  allows  the  development  of  paBerns  of  aBachment  which  lead  to  an  internal  working  model  of  aBachment  which  is  applied  throughout  life.      

SeparaEon  anxiety  and  grief  following  the  loss  of  an  aBachment  figure  is  a  normal  and  adapEve  response  in  an  aBached  infant.      

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Common Misunderstandings About Attachment

There is only one period in which attachments are formed or damaged.

Early childhood is critical, but there is no point that repairs cannot be made or damage can be done.

A secure attachment provides ‘inoculation’. Secure attachments serve as buffers, not inoculations.

We can predict children’s development based on their early attachments.

Developmental predictions are probabilistic. The balance between risk and protective factors is key.

David Oppenheim, PhD 7  

Common Misunderstandings About Attachment

Children do not become attached to maltreating parents (or can easily detach from them).

Children attach to maltreating parents and separation will be experienced as a loss. Children’s relationship with their mothers are the most important.

Children can develop attachments to several caregivers.

Children do not have memories of their early years, and therefore they do not have lasting impact.

Children do not have declarative memories but may have procedural memories encoded in their internal working model.

David Oppenheim, PhD 8  

Why Is Attachment Important?

The  quality  of  caregiver/child  relaEonship  has  a  profound  effect  on  child’s  social-­‐emoEonal  development,  

personality  formaEon  and  social  competence.    

Infants  develop  a  ‘sense  of  self’  through  relaEonships  with  

other  people.  

Informs  child’s  view  and  engagement  in  future  relaEonships  

Influences  ability  to  maintain  commitments  to  work  and/or  school  

as  older  child  and  adult  

Influences  ability  to  raise  healthy,  happy  children  of  their  own  

Impacts  child’s  ability  to  focus  on  learning  and  growing  

Builds  trust,  empathy,  conscience,  and  compassion  for  others   9  

Emotional Stages for Engagement

Active initiation – baby protests when attachment figure leaves and actively pursues them by approaching, following, and greeting upon reunion (6/8 months to 24 months)   Stranger anxiety – Infant crying when unfamiliar person

approaches (8/9 months to 24 months)

Separation anxiety – Infant cries when attachment figure leaves and is calmed when they returns (6/7 months to 10/18 months)

Undiscriminating – baby responds to anyone (up to 3 months old)  

Differential responsiveness – baby knows and prefers mother (after 4 months to 9 months)  

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Strange Situation Study

The study involved observing children between the ages of 12 to 18 months responding to a situation in which they were briefly left alone and then reunited with their mother.

Mary AINSWORTH, 1978

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hBp://www.youtube.com/watch?v=s608077NtNI  

Below is the link to the Strange Situation video on Youtube.com. The video demonstrates various types of attachments between children and their mothers, as triggered by the presence of a stranger.*

*If wireless or internet access is available, simply click the link to play the video during the presentation. If wireless or internet is not available, please refer to the Session #3 training guide for a description of how to embed the video into the PowerPoint ahead of time in order to show it during a training session.

Rhesus Monkey Experiment

Harry HARLOW, 1958

The controversial experiment involved giving young rhesus monkeys a choice between two different "mothers." One was made of soft terrycloth, but provided no food. The other was made of wire, but provided food from an attached baby bottle.

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hBp://www.youtube.com/watch?v=hsA5Sec6dAI  

Below is a link to Youtube.com that enables trainees to see a video of Harlow’s research on attachment in monkeys. The video shows the experiments that were run to trigger and observe the attachment of several monkey “subjects” to two different artificial monkey “mothers”.* *If wireless or internet access is available, simply click the link to play the video during the presentation. If wireless or internet is not available, please refer to the Session #3 training guide for a description of how to embed the video into the PowerPoint ahead of time in order to show it during a training session.

A child who experiences responsive, nurturing and consistent caregiving is more likely to be securely attached and have a positive self image. This optimistic view of self extends to others who are perceived as trustworthy, caring and protective

Secure or Insecure

A child who experiences inconsistent, unresponsive or insensitive caregiving can develop an insecure attachment style and have an internal working model that perceives themselves, their environment and others negatively or as untrustworthy.

Securely Attached

Insecurely Attached

What does it take?

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Is Bonding Attachment? No.

Bonding is the way an adult develops an emotional connection to a child e.g., cuddling, smiling, playing, feeding, listening, talking.

These activities are necessary for the child to develop a positive attachment, but they are not sufficient in and of themselves.

Attachment requires a relationship between the child and caregiver. It is not something the caregiver does to or for the child, it is a

reciprocal relationship.

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Secure Attachment

Attachment Patterns

•  65% of general population has Secure Attachment

•  Child: Explore freely when caregiver is present. Typically will engage with strangers. Visibly upset when caregiver leaves and happy when they return.

•  Child’s world view: Trusts that his needs will be met

•  Attachment figure: Quick to respond, sensitive, consistent

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Anxious-Avoidant Attachment (Insecure)

Attachment Patterns

•  20% of general population has Anxious-Avoidant Attachment

•  Child: Not very explorative, emotionally distant, often ignore/avoid caregiver upon reunion. Strangers not treated differently than caregiver.

•  Child’s world view: Subconsciously believes his needs will not be met

•  Attachment figure: Distant, disengaged or little engagement

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Anxious-Resistant Attachment. OR

Ambivalent Attachment (Insecure)

Attachment Patterns

•  10-15% of general population has Anxious-Resistant or Ambivalent Attachment

•  Child: Anxious, insecure, angry. Wary of strangers, even when caregiver is

present. Highly upset upon separation but ambivalent upon reunion with caregiver

•  Child’s world view: Can’t consistently rely on her needs being met

•  Attachment figure: Inconsistent, sometimes sensitive, sometimes neglectful

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Disorganized Attachment (Insecure)

Attachment Patterns

•  10-15% of general population has Disorganized Attachment

•  Child: Depressed, angry, completely passive, nonresponsive. Will sometimes freeze. No organized, behavioral way to deal with stress. Often see caregiver as frightening or frightened.

•  Child’s world view: Severely confused with no strategy to have his needs met

•  Attachment figure: Distant, disengaged, aggressive, frightened

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Reactive Attachment Disorder

Children with reactive attachment disorder (RAD) have been so disrupted in early life that their future relationships are also impaired. They have a markedly disturbed and developmentally inappropriate way of interacting with others and are often developmentally delayed. Inhibited symptoms of RAD: The child is extremely withdrawn, emotionally detached, and resistant to comforting. The child is aware of what’s going on around him or her—hypervigilant even—but doesn’t react or respond. He or she may push others away, ignore them, or even act out in aggression when others try to get close.

Disinhibited symptoms of RAD: The child doesn’t seem to prefer his or her parents over other people, even strangers. The child seeks comfort and attention from virtually anyone, without distinction. He or she is extremely dependent, acts much younger than his or her age, and may appear chronically anxious.

RAD

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Circle of Security

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A good match between an infant and primary caregiver, “goodness of

fit”, facilitates secure and positive attachment;

Similarly, a poor match hinders it, leading to an insecure attachment.

When there is a mismatch, the adult must adjust rather than the infant.

Temperament and Goodness of Fit

Temperament of the infant can affect attachment

in either positive or negative ways.

Categories of Temperament:

Fearful, Flexible and Feisty  

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Serve and Return can be compared to a game of tennis. Infants and toddlers naturally reach out for interaction through babbling, facial expressions, gestures etc. Adults respond with the same kind of vocalizing and gesturing. This ‘serve and return’ continues back and forth. When unreliable, inappropriate or absent, the developing architecture of the brain may be disrupted – having devastating effects for the future.

Serve and Return Let’s play….

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Still Face Experiment Ed TRONIK, 1975

The phenomenon in which an infant, after three minutes of “interaction” with a non-responsive expressionless mother, “rapidly sobers and grows wary. He makes repeated attempts

to get the interaction into its usual reciprocal pattern. When these attempts fail, the infant withdraws [and] orients his face

and body away from his mother with a withdrawn, hopeless facial expression.”

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hBp://www.youtube.com/watch?v=GeJAGozM6SA  

Below is the link to the Still Face video. This shows “serve and return” interactions between an infant and mother followed by the reaction of the infant when the mother becomes “still faced” during the experiment.*

*If wireless or internet access is available, simply click the link to play the video during the presentation. If wireless or internet is not available, please refer to the Session #3 training guide for a description of how to embed the video into the PowerPoint ahead of time in order to show it during a training session.

Stages of Emotional Reaction In Response to

Separation and Loss

Detachment:  child  is  indifferent  to  care  from  primary  caregiver,  does  not  connect  with  caregiver  and  no  longer  responds  when  

caregiver  leaves      

Despair:    child  is  losing  hope  of  being  reunited;  becomes  depressed  and  disinterested  in  surroundings  

and  food  

Protest:  child  is  frightened  and  confused,  screaming  and  anxiously  

looking  for  primary  caregiver  

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Positive Stress

Stress Types

Tolerable Stress

Toxic Stress

Strong, frequent or prolonged adversity such as physical, emotional abuse, chronic neglect. Creates stress response that disrupts development of brain architecture and other organ systems. Body’s stress response system is always or frequently on.  

Activates body’s alert system in cases such as loss of loved one, natural disaster, frightening injury. Time limited activation and buffered by responsiveness of adults in child’s life. Brain and organs recover from stress.  

Normal and part of healthy development. Brief increase in heart rate, mild elevation in hormone levels. Ex. first day at new child care or receiving immunizations

A little bit of stress can be a good thing.

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Trauma can be “a single event, connected series of traumatic events, or chronic, lasting stress… Trauma is the direct experiencing or witnessing of an event(s) that involves actual or threatened death, serious injury, or threat to the psychological or physical integrity of the child or others”.

Diagnostic Classification: 0-3R

Trauma…What Is It?

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TYPE 1 Single Incident

TYPE 2 Chronic

TYPE 3 Complex Cumulative

Single Exposure Single type (like abuse) repeated over a period of time, or variety of types

Repeatedly, cumulative, and usually increases over time

Post-traumatic Growth possible (PTG) - Healing

Can separate incidents Anxiety Resiliency Accessible Impaired functioning but managing PTG possible

Cannot separate incidents Anxiety Resiliency lost Impaired functioning in all areas Psychiatric manifestations PTG is much more difficult

Ex. Crime victim, serious accident, natural disaster

Ex. Domestic violence, abuse, war

Ex. Ongoing physical or sexual abuse, war, captivity

Types of Trauma

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Behaviors in Traumatized Infants and Toddlers

Chronic feeding or sleeping difficulties Engages in compulsive activities (head banging)

Inconsolable, ‘fussiness’ or irritability Throws wild, despairing tantrums

Incessant crying with little ability to be consoled

Displays repeated aggression or impulsive behaviors

Extreme upset when left with another adult Difficulty playing with others

Inability to establish relationships with other children or adults

Little or no communication; lack of language

Excessive hitting, biting and pushing of other children

Loss of earlier developmental achievements

Very withdrawn behavior Separation anxiety

General fearfulness/new fears Easily startled

Repetitive/post-traumatic play Constricted play, exploration, mood

In  part  from:  Helping  Young  Children  Succeed.      Strategies  to  Promote  Early  Childhood  Social  and  EmoEonal  Development  Julie  Cohen.    ZERO  TO  THREE   31  

Domain Specific Signs of Trauma In Infants and Toddlers

NaEonal  Child  TraumaEc  Stress  Network  

Attachment Physical Affect Regulation Behavioral Control

Cognition Self-Concept

Difficulty trusting others

Sensorimotor problems

Problems with emotional regulation

Poor impulse control

Difficulty paying attention

Lack of predicable sense of self

Uncertain about predictability of others

Hypersensitivity to physical contact

Easily upset and/or difficulty calming

Self-destructive behavior

Lack of sustained curiosity

Poor sense of separation

Interpersonal difficulty

Somatization Difficulty describing emotions

Aggressive or oppositional behavior

Problems processing information

Disturbance of body image

Social Isolation Increased medical problems

Difficulty knowing internal state

Excessive compliance

Problems focusing/ completing tasks

Low self-esteem

Difficulty seeking help

Problems with coordination/ balance

Problems with communicating needs

Sleep and eat disturbances

Difficulty anticipating consequences

Shame

Clingy, difficulty with separations

Reenacting of traumatic event

Learning difficulties/ developmental delays

Guilt

Pathological self-soothing practices

Problems with language development

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Increased chance of obesity Increased chance of stroke, diabetes, cardiovascular disease, cancer and early death Lower job performance Greater likelihood of substance abuse Greater risk of depression Increased suicide attempts S Sexual promiscuity

Long Term Impact of Trauma Adverse  Childhood  Experiences  (ACE)  Study  

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What Protects a Child During Trauma?

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Protective Factors These are associated with resistance to

stress •  Intelligence •  Capacity for emotional

regulation

•  Social support from competent, caring caregivers

•  Positive beliefs about self •  Positive beliefs that the world

is safe, predictable and fair

•  Self-efficacy and motivation to take positive actions on behalf of self Where have we seen these factors

before?….Secure Attachment! 35  

Building Resiliency

•  A secure attachment to a caring adult •  Relationships with positive role

models

•  Opportunities to learn skills •  Opportunities to participate in

meaningful activities •  Confidence •  Positive outlook

•  Self control

Resiliency is the ability to steer through serious life challenges and find ways to bounce back and thrive.

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Caregiver Responsiveness

Effects of trauma on children can be mitigated by the presence of a supportive caregiver, even if the caregiver is unable to alter the outcome of events

Luthar & Zigler (1991) 37  

How Can Caregivers Help?

Talk, read and sing to and have conversations with child.

Ensure health, safety and good nutrition. Help children feel safe and secure.

‘Serve and Return’ with them consistently.

Encourage safe exploration and play.

Establish routines. Really listen to children and respond to their cues, verbal and non-verbal. Be responsive to crying. Remove physical threats.

Be a consistent, responsive and loving caregiver.

Look through trauma lenses when engaging with child

Minimize stress to keep Cortisol levels low. Seek professional help when

needed.

Be sensitive around transitions.

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•  Dyadic Developmental Psychotherapy:

•  Infant – Parent Psychotherapy

•  Child – Parent Psychotherapy (CPP)

•  Attachment Self – Regulation and Competency

(ARC)

•  Play therapy for children 2/3 yrs. and older

Therapeutic Interventions

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Cutchins Children’s Clinic: (413) 587-3265 (has been trained in CPP) CHD (Center for Human Development):

Easthampton – (413) 529-1764 Greenfield – (413) 774-6252 Orange – (978) 544-2148 Athol – (978) 830-4120

CSO (Clinical and Support Options):

Hampshire – (413) 582-0471 Franklin (413) 774-1000

Service Net: Main intake: (877) 984-6855

*Behavioral Health Clinics in Northampton, Amherst and Greenfield have been trained in ARC Hampshire – (413) 585-1300 Franklin – (413) 772-2935

Resources and Referrals *When referring, ask for a clinician with early childhood expertise and training

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Session  4  IECMH  Best  PracEces  –  EffecEve  CollaboraEon  and  SupporEng  Resiliency  

Session  5  Case  Conferencing  and  CollaboraEon    Joint  Session  with  Child  Welfare  staff  

What’s Coming Up?

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Contact  us!    

Sarah  Lusardi,  MSW  slusardi@collaboraEve.org;    413-­‐586-­‐4998  x  107  

 Alison  Morrisey,  LCSW  

amorrisey@collaboraEve.org;  413-­‐586-­‐4998  x105        

The Impact of Trauma and

The Importance of Attachment

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