Keeping Attachment Intact Following Trauma

Douglas Goldsmith, Ph.D.Executive Director

The Children’s Center18th Annual Conference on Child Abuse & Family Violence

October 2005

Special Thanks

Dr. David Oppenheim University of Haifa

Dr. Janine Wanlass Westminster College

For their contributions and support on conceptualizing issues around attachment and permanency

Overview

What is a “secure base” and why is it important?

What happens when children are separated from their caregiver?

What should we do to foster a secure attachment after trauma and loss?

Development of Attachment

Biological process

Recognition of the caregiver

Utilization of the caregiver as

a “haven of safety” and a

“secure base” in order to

explore the environment

Attachment Behaviors

Approach the caregiver

Crying

Seeking contact

Maintaining the contact

The number of attachment behaviors will vary with the degree of the perceived threat in the environment

Weinfield et al (1999)

Secure vs Insecure Attachment

The classifications “Secure” vs “Insecure” “Reflect the infant’s apparent perception of the availability of the caregiver if a need for comfort or protection should arise, and the organization of the infant’s responses to the caregiver in light of those perceptions of availability.”

Weinfield et al (1999)

Impact of Attachment

Whether a child or adult is in a state of security, anxiety, or distress is determined in large part by the accessibility and responsiveness of the principle attachment figure.

Bowlby (1973)

Secure Attachment

The caregiver is perceived as a reliable source of protection and comfort

Secure Attachment

When I am close to my loved one I feel good, when I am far away I am anxious, sad or lonelyAttachment is mediated by looking, hearing, and holdingWhen I’m held I feel warm, safe, and comfortedResults in a relaxed state so that one can, again, begin to explore

•Holmes (1993)

Secure Attachment

Attachment is a reciprocal relationshipThe parent offers caregiving behavior that matches the attachment behavior of the child The child, using social referencing, checks in with the mother “looking for cues that sanction exploration or withdrawal”

Holmes (1993)

Anxious Attachment

Maintain constant low levels of anxiety about the caregiver’s availability

Unable to explore the environment without worry

Fail to achieve confidence in themselves and mastery of their enviroment

Weinfield et al (1999)

Response to Separation

Increased fear

Increased anger

Hostile behaviors increase and may persist

Sadness, withdrawal, disengagement

Hatred and resentment may be accompanied by desire to harm parents

Children’s Response to Trauma

Loss of sense of basic trustLoss of securityDestabilized “Secure Base”

Compromised emotional development

Impact of Parental Depression

Children: Show more depressed affect Show more behavior problems Maladaptive interactions with parents

Field (1987, 1995)

Impact of Parental Anxiety

Unable to hear their children’s distress

Withdraw to protect themselves emotionally

Difficulty tolerating children’s anxiety and aggression

Osofsky & Fenichel, (1994, 1996, 2000)

PTSD Post Traumatic Stress Disorder

Persistent re-experiencing of trauma

Avoidance of stimuli associated with trauma

Increased arousal

Impairments in social, emotional, and occupational functioning

PTSD à deux

“ The parents own traumatic response to the trauma endured by the child creates a complex system that may maintain or contribute to dysfunction in both parent and child”

Appleyard & Osofsky (2003)

Relational PTSD

Parents may be traumatized even if not present at the trauma: Withdrawn/Unresponsive/Unavailable

Emotionally and functionally unavailable May have suffered trauma in the past

Overprotective/Constricting Preoccupied about the trauma re-occuring

Reenacting/Endangering/Frightening Repeatedly ask about the event

Scheeringa & Zeanah (2001)

Infants and Toddlers

Following violence in their home or community: Increased irritability Immature behavior Sleep disturbances Emotional distress & crying Fears of being alone Physical complaints Loss of skills – regression in toileting and language Increased separation distress

Appleyard & Osofsky (2003)

Young Children

Re-experiencing of the traumatic event

Avoidance

Numbing of responsiveness

Increased arousal

Fear going to sleep to avoid nightmares

Restricted range of emotion in play

Serious, disorganized, somberAppleyard & Osofsky

(2003)

Access to early memories

22 children 8-10 year oldsShown photos of preschool classmatesUnable to consciously identify the picturesBut pictures of children with whom they were familiar elicited reliable skin conductance responsesEarly memories may remain even after conscious recall disappears Vaughn & Bost (1999)

Memory of the trauma

First weeks of life Infants can recognize stimulus cues associated

with trauma and show distress reactions

Three to four months Recognition of trauma and distress can persist

for weeks to months

Six to twelve months Internal representation of the trauma as seen

through play Gaensbauer (2002)

The Case of Sara

Placed for adoption upon discharge from the hospital5 months of age legal adoption is not completedSara enjoys a loving relationship with her parentsThe parent child relationship is marked by reliable, emotionally attuned, and responsive care

The Case of Sara

Allegations of neglect ariseSara is removed from the home at the age of 10 months

The Case of SaraShelter home for four days

Second foster home for one week

Third foster home for eight weeks

Adoptive home

The Case of Sara

Upon arrival to the adoptive home Sara stares blankly, refuses social interaction, and is oblivious to pain after undergoing a medical procedureBelieving that Sara is available for adoption her name is changed

The Case of Sara

At the age of 15 months Sara is responding well to her new environmentFirst adoptive family hasn’t seen her for 6 months and want her returned to their care

The Case of Sara

Should she return?Who are the “psychological” parents?Does she remember her first adoptive parents?She’s so young that she won’t remember anything and can be returned without distressSara is a “resilient” child

The Case of Sara

The internal working model – viewing the world through Sara’s eyesAssessing “risk”Could reunion reactivate feelings of loss?Utilization of second adoptive parents as a secure baseImpact of no contact

Factors Favoring Sara’s Return

Sara is a “resilient” child and can weather more moves.

Sara needs to return to be able to resolve her grief

As she gets older, Sara will long to be with her first adoptive family

Sara should not have been removed in the first place

Factors AgainstSara’s Return

Length of time away from her first family without any contact

Her name change has impacted her Internal Working Model

She now views her new family as her only family and calls her new parents “mama” and “dada”

Factors Against Sara’s Return

Sara clearly shows signs of a secure attachment to her new parents

A return could, in fact, be viewed by Sara as traumatizing and as being “ripped away” from her family

Trauma could create a Reactive Attachment Disorder

Factors Against the Return of Sara

Comparing the future stability of the two families First family is struggling with high levels of

stress and their relationship has been negatively impacted and, largely ignored

Second family has, and will likely, withstand stressors

Implications for Caseworkers

Request relationship-based assessmentsUnderstand children’s needs vs. parental capacity for caregivingDevelop specific recommendations about what behaviors the parent needs to develop to successfully parent this particular child

Use of Supervised Visits

Used routinely but should be used for extreme cases where abuse/neglect even under supervision is of high risk

Need to find ways to allow for more contact with parents in a more natural setting Use of foster parents as peer parents

Therapeutic visits vs. supervised visits

Supervised Visits

Be mindful of the limits to interpretation of the behaviors between the parent and child Playfulness does not equal attachment

Stress following the visit is natural and should not necessarily be interpreted to mean that visits are experienced negatively by the child

Observation of Parent-Child Relationship

Observe proximity seeking behaviors – watch eye contact and social relatedness

Observe parental sensitivity and insightfulness to child’s cues

Who does child seek out when frustrated or frightened

Use doll play to assess attachment hierarchy

Assessment

Assess parental response to the trauma

Assess pre and post family functioning

Assess impact on attachment system Can child continue to utilize parent as a secure

base?

Availability of family support system

Intervention

Increase protection for highly anxious children Temporarily change sleeping arrangements Actively demonstrate safety Allow child to maintain closer proximity when

possible Decrease toileting demands on very young

children Increase use of transitional objects

Intervention

Increase structure to manage acting out behaviors Remind children that rules haven’t changed Continue with consequences Increase communication and help child

understand their response to trauma

Intervention

Limit access to television and radio broadcasts

Increase reassurance

Maintain routines

Encourage parents to take care of their own mental health needs

Intervention

Attempt, within limits of safety issues, to maintain close contact between the children and their primary caregiver