Keeping Attachment Intact Following Trauma

1. Keeping Attachment Intact Following Trauma Douglas Goldsmith, Ph.D. Executive Director The Children’s Center 18th Annual Conference on Child Abuse & Family Violence October 2005

2. 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

3. 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?

4. 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

5. 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)

6. 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)

7. 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)

8. The caregiver is perceived as a reliable source of protection and comfort Secure Attachment

9. Secure Attachment • When I am close to my loved one I feel good, when I am far away I am anxious, sad or lonely • Attachment is mediated by looking, hearing, and holding • When I’m held I feel warm, safe, and comforted • Results in a relaxed state so that one can, again, begin to explore • Holmes (1993)

11. Attachment is a reciprocal relationship The 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) Secure Attachment

12. 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)

13. 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

14. Children’s Response to Trauma • Loss of sense of basic trust • Loss of security • Destabilized “Secure Base” Compromised emotional development

15. Impact of Parental Depression • Children: • Show more depressed affect • Show more behavior problems • Maladaptive interactions with parents Field (1987, 1995)

16. 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)

17. 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

18. 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)

19. 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)

20. 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)

21. 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, somber Appleyard & Osofsky (2003)

22. Access to early memories • 22 children 8-10 year olds • Shown photos of preschool classmates • Unable to consciously identify the pictures • But pictures of children with whom they were familiar elicited reliable skin conductance responses • Early memories may remain even after conscious recall disappears Vaughn & Bost (1999)

23. 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)

24. The Case of Sara • Placed for adoption upon discharge from the hospital • 5 months of age legal adoption is not completed • Sara enjoys a loving relationship with her parents • The parent child relationship is marked by reliable, emotionally attuned, and responsive care

25. The Case of Sara • Allegations of neglect arise • Sara is removed from the home at the age of 10 months

26. The Case of Sara Shelter home for four days Second foster home for one week Third foster home for eight weeks Adoptive home

27. 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 procedure • Believing that Sara is available for adoption her name is changed

28. The Case of Sara • At the age of 15 months Sara is responding well to her new environment • First adoptive family hasn’t seen her for 6 months and want her returned to their care

29. 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 distress • Sara is a “resilient” child

30. The Case of Sara • The internal working model – viewing the world through Sara’s eyes • Assessing “risk” • Could reunion reactivate feelings of loss? • Utilization of second adoptive parents as a secure base • Impact of no contact

31. 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

32. 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”

33. 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

34. 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

35. Implications for Caseworkers • Request relationship-based assessments • Understand children’s needs vs. parental capacity for caregiving • Develop specific recommendations about what behaviors the parent needs to develop to successfully parent this particular child

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. Intervention • Limit access to television and radio broadcasts • Increase reassurance • Maintain routines • Encourage parents to take care of their own mental health needs

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