SarahLusardi,MSW July24,2013 - Collaborative...Reactive Attachment Disorder Children with reactive...
Transcript of 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 [email protected]; 413-‐586-‐4998 x 107
Alison Morrisey, LCSW
[email protected]; 413-‐586-‐4998 x105
The Impact of Trauma and
The Importance of Attachment
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