The Impact of Attachment Trauma on Child Development

1. The Impact of Attachment Trauma on Child Development Creating Connections to Shining Stars Virginia Beach 17 July 2012 Jane C. Probst, MSW Rappahannock Rapidan Community Services Child & Family Clinical Services jprobst@rrcsb.org

2. Overview • Expanding Perceptions of Trauma • Childhood Trauma: Early Lessons Last a Lifetime • Diagnosing Childhood Trauma: DSM IV Criteria Existing Diagnoses • Trauma Researcher’s DSM V Proposals - Thinking Differently • DSM V Considered Diagnoses Changes – May 2013 • Why Diagnoses Matter • Adverse Childhood Experiences Study (ACE) • ACE Adult Findings • ACE Co-Morbid Groups • Childhood into Adulthood Outcomes • Find Your ACE Score - PDF Score Sheet • Why Diagnoses Don’t Matter • Considering Trauma Treatment • References & Recommended Readings • Questions & Comments

3. Expanding Perceptions of Trauma • Natural Environment Traumas • Hurricanes, Earthquakes, Volcanoes, Floods, Fires - Random • Transportation Traumas • Vehicular Accidents: Land, Sea, Air - Random • Community Violence • Terrorist Attacks- Random • War, Ethnic & Cultural Discrimination – Time and place specific • Personal Violence • Stranger Danger, Assaults, Robbery, Sexual Assault/Rape – Random • Interpersonal Violence • Domestic Violence, Partner Abuse, Intimate Partner Violence • Occurs within the context of a relationship and is time-relative • Attachment Trauma and Early Childhood Trauma • Age of onset of trauma & trauma symptoms are inversely correlated • The younger the age of onset, the more complex the cascade of symptoms

4. Actually, on a cellular level, I’m very busy… Infants are born with their fully developed & largest sensory organ – skin! And ready to receive the initial stimulus to begin building neural connections.

5. Childhood Traumas: Early Lessons • What is Attachment and Attachment Trauma? • Secure or Insecure Attachment, Internal Working Model • Mother/primary caregiver is infant’s whole world • Reciprocal & symbiotic self-regulate emotions & return to homeostasis • Infants 1st job is to regulate body temperature and functions at birth • AT is chronic, accumulative, and compromises learning • “Inversely related to the age of onset of first trauma, such that those with early life trauma are more likely to manifest” and accumulate symptoms throughout the lifespan. (van der Kolk et al., 2005) • Natural trauma survival response options in “limbic animals” • Fight: infant has no physical power over abuser • Flight: source of safety is source of abuse/neglect place child in a double bind • Freeze – only option available to infants & children • Restricted brain development & integration in “freeze” state; flooding & restriction of hormones • Lesson learned to numb – set up for later maladaptive coping • Pronking – exhilarated leaping into the air when contact with predator avoided • Defensive mechanism, warning to others of danger, exhilaration at survival • Polyvagal Theory 10th cranial nerve: evolution of Sympathetic & Parasympathetic NS (Porges, 2011) • Emotional & physiological regulation synchronized with internal organ regulation • Bidirectional signals: 80% afferent (incoming) 20% efferent (outgoing).

6. Childhood Traumas: Early Lessons • Birth to 18 m. predominate right hemisphere development • Implicitly learned recognition: facial features, tone of voice, incidental environmental cues • Incidental verbal/non verbal cues to the safety/danger from caregivers & environment • Earliest implicit memories form outside awareness and become hard-wired • Mirror neurons reciprocate all emotions, not just 6 we’re born with • Teaches emotion and self-regulation simultaneoulsy • Neurons that fire together, wire together (Hebbs, 1949) • The initial seeds of sympathy and empathy • Facial expressions, tone of voice, heart and breath rates model regulation or dysregulation

7. Diagnosing Childhood Trauma • PTSD: Anxiety Disorder w/Discrete Event – Not a Child Focused Dx • DSM-V change PTSD to Trauma & Stressor Related Disorders – child focused • Ignores accumulative layers of chronic trauma, abuse & neglect • Disorder Extreme Stress Not Otherwise Specified - DESNOS • Captures complex trauma symptomatology • Not recognized by APA as a diagnosis, however clinicians use it as specifier • Reactive Attachment Disorder • Does not consider trauma outside of attachment with caregivers • Many professionals consider it an inaccurate diagnosis > 8 y.o. • Multiple Co-Morbid I, II, III Dx • Diagnostic behaviors are very disorganized & dysregulated; diagnoses difficult • ADHD, Bipolar, Conduct Disorder, ODD, Intermittent Explosive Disorder • Accurate assessments for early interventions • Critical learning periods are interrupted/disrupted/mitigated • Cascading impairments are accumulative and undeterminable • Restricts neural development, accelerates pruning

8. Researcher’s DSM V Proposals • Developmental Trauma Disorder (van der Kolk, 2005) • Comprehensive criteria targeting children • Under consideration by APA for DSM V • Field trials ongoing ; criteria info at www.traumacenter.org • Disorders of Extreme Stress NOS – DESNOS • Not accepted by APA but used as a ‘qualifier” • Can be Co-Morbid with PTSD Diagnosis • Different criteria from PTSD • PTSD - Organized Attachment (Classen et al., 2006) Rejected • Caregiver is not the abuser, however, caregiver is not protective • Poverty, DV, substance abuse, chronic A & N by others • Invisible, Parentified, Secretive • Hiding in plain sight • PTSD - Disorganized Attachment (Classen et al., 2006) Rejected • Caregiver is the abuser • Significant affect dysregulation • Narrow window of tolerance • Approach-avoidant behaviors: caregiver is abuser

9. DSM-V APA Considered Diagnoses • Trauma & Stressor Related Disorders: All Ages • Reactive Attachment Disorder, child is > 9 months • A & N by caregivers, incidental social cues of contempt & disregard • Disinhibited Social Engagement Disorder > 9 months • Multiple caregivers, indicative of children in chronic foster care • PTSD in Preschool Children < 6 years old • Acute Stress Disorder (no age limiting criteria) • Adjustment Disorders • Current subcategories with additions (PTSD/ASD symptoms) • Other Specified Trauma/Stressor Related Disorder • Unspecified Trauma/Stressor Related Disorder • No criteria determined at this time for either of the above • Developmental Trauma Disorder (van der Kolk, 2005) • For diagnoses & criteria info: www.dsm5.org

10. Why Diagnoses Matter • ATTACHMENT & ATTACHMENT TRAUMA HAPPEN AT CELLULAR LEVEL • Implicit memory begins in utero and is hard-wired • Inability of integrated narrative ability – left & right brain integration • Restricts critical periods of brain structure development & myelination • Stress hormones (cortisol, adrenalin, norepinephrine) flood brain/body • Body/brain develop with a baseline of stress hormones • Baseline lasts a lifetime without intervention. • Body regulation through CNS is infant’s main job from birth • Identify Dx for prevention, intervention, and treatment • Formulation & Implementation of Ethical MH Policies for Children • Attachment Styles are Generational (Hesse, 1999) • 75% correlation attachment styles between generations (Schore, 2000) • Intervention reduces generational cycles of chronic abuse • USDHHS (2002) – identified 870,000 abused/neglected children in US • 83.3% abused by primary caregiver • Infants to age 3 with highest rates of victimization and death • Research for evidence based treatments • All Axes considered for holistic functioning • Mental health: neurobiologically, physiologically, and medically necessary for survival • Attachment Theory - Darwin meets Freud!

11. ACE Longitudinal Study1998 Kaiser Permanente & CDC • Adverse Childhood Experiences – ACE (n=13,494) • Identified 7 categories of abuse (self-reporting) • Substance abusing family member – 25.6% • Sexual abuse – 22% • Mental illness of caregiver – 18.8% • Violence against the mother – 12.5% • Psychological Abuse -11.1% • Physical Abuse - 10.8% • Family member incarcerated – 3.4% • Poverty & economic risk factors not considered • In depth outcome details: www.acestudy.org

12. ACE Adult Findings Substance Abuse family member exposed to other category (N=2064) Mental illness of caregiver – 34% Sexual Abuse – 34% Violence against the mother – 29% Psychological Abuse – 22% Physical Abuse – 19% Family member incarcerated – 8% Violence against mother exposure other category (N=1010) Substance abusing family member 59% Sexual Abuse – 41% Mental illness of caregiver – 38% Psychological Abuse – 34% Physical Abuse – 31% Family member incarcerated – 10% Witnessed assault with knife or gun – 3% (Felitti et al., 1998)

13. Groups ≥ 4 of 7 Self-Report • Any combination of 4 or more groups: • Depression for 2 weeks in past year – 50.7% • Illicit drug Use – 28.4% • No leisure time/activity – 26.6% • Suicide attempts – 18.3 % • Smoking - 16.5% • Self identified alcoholic – 16.1% • Obesity - 12% • ≥ 50 Sexual partners – 6.8% • STI’s – 6.8%

14. Childhood to Adulthood Health Outcomes • ACE Adult Health Outcomes Studied & Published: • Chronic Disease: Lung Cancer, Heart Disease, Autoimmune • Health Risks: Alcohol & Drug Abuse, Obesity, Smoking • Mental Health: Depression, Suicidality, Work Absenteeism • Victimization & Perpetration: Intimate Partner Violence • Sexual Behavior: Fetal Death, Teen Pregnancy, STD’s • Autobiographical Memory Disturbances • Impaired implicit and narrative memory • Special Populations Studies • Child Sexual Abuse Victims, Children of Alcoholics, War Refugees • www.cdc.gov/ace/outcomes.htm • Strong Correlations Between Attachment Trauma & PD • 75% of BPD are women (DSM-IV-TR, 2000) w/history of multiple AT • Insecure attachment risk factor for PTSD severity in veterans (Renaud, 2008)

15. Finding Your ACE Score 092406RA4CR While you were growing up, during your first 18 years of life: 1. Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt? Yes No If yes enter 1 ________ 2. Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? Yes No If yes enter 1 ________ 3. Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you? Yes No If yes enter 1 ________ 4. Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other? Yes No If yes enter 1 ________ 5. Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? Yes No If yes enter 1 ________

16. Finding Your ACE Score 6. Were your parents ever separated or divorced? Yes No If yes enter 1 ________ 7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? Or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Or Ever repeatedly hit at least a few minutes or threatened with a gun or knife? Yes No If yes enter 1 ________ 8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? Yes No If yes enter 1 ________ 9. Was a household member depressed or mentally ill, or did a household member attempt suicide? Yes No If yes enter 1 ________ 10. Did a household member go to prison? Yes No If yes enter 1 _______ Now add up your “Yes” answers: _______ This is your ACE Score. Higher the score, higher the risk consequences of Adverse Childhood Event (Felliti & Anda, 1998) For ACE Score diagnostic tool in Spanish, French, Icelandic, Norwegian, & Swedish http://www.acestudy.org/yahoo_site_admin/assets/docs/ACE_Calculator-English.127143712.pdf

17. Why Diagnoses Don’t Matter • 1st Rule - DO NO HARM • Constellation of Symptoms = Constellation of Treatments • Individualized with engaged client • Sequenced and strength-based • Safety, Stabilization, skill building, therapeutic alliance, • Trauma processing, narrative integration, meaning of self identity • Psycho-education to normalize symptomatology • Bottom-up and top-down treatments • Build Therapeutic Alliance Regardless of Diagnoses • Attachment repair, mirror neurons, holding environment • Darwin meets Freud! • Affect & Physiological Regulation (physical and emotional regulation) • Widen the window of distress tolerance • Recounting trauma can re-traumatize – vicarious trauma considerations • Impaired Integration & Transition of Developmental Stages • Implicit memories & narrative abilities - consider developmental age of client • Critical learning periods: affect regulation, language, concrete/abstract thinking

18. Considering Trauma Treatments • Treatment and assessment are ever-evolving • Circling back to crisis & stabilization with newly acquired skills • Interventions can be in the moment – trusting the client! • Clinical agility and attunement • It’s never one thing…… • Chemical reactions are cascades of reactions & catalysts • People are walking talking feeling emoting chemical reactions • Emotions are necessary physiological processes dependent on the CNS • Treatments focus on outcome may miss the “Lessons Learned” • Developmental age vs. chronological age • Meet the client developmentally • Under stress we regress (stunted affect, dysregulated behaviors, etc.) • Cyclical groundwork • Attachment, Attunement, Alliance & Affect Regulation • Trust your client to give you metaphors & analogies • Psycho-education of CNS normalizes trauma sequelae • Panic attacks, nausea, somatization • Parasympathetic NS versus Sympathetic NS

19. Considering Trauma Treatments • Connection & vulnerability – taking worthwhile risks • Brené Brown www.tedtalks.com (20 minute video) • Neuroplasticity: positive physical activity integrates experiences • Simultaneous regulation through combined sequenced therapies • Top-down (cognitive talk-based) & Bottom-up (experiential) therapies • Cognitive Processing Therapy – structured 12 sessions includes writing • CBT with Prolonged Exposure • EMDR – Eye Movement & Desensitization & Reprocessing adults & kids • Sensorimotor Psychotherapy – mind/body/spirit (Pat Ogden) • Attachment, Self-Regulation & Competency – ARC • Margaret E. Blaustein & Kristine M. Kinniburgh (2010) • Experiential learning through repetition rewires brain • Procedural memory strengthens (long-term & implicit) • Integrate implicit and explicit memories to narrative change of IWM • Client is focus, not the trauma • Questions-comments-contributions-insights?

20. References • Ahrens, J., & Rexford, L. (2002). Cognitive processing therapy for incarcerated adolescents with PTSD. Journal of Aggression, Maltreatment & Trauma, 6(1), 201-216. • Axelrod, S. R., Morgan, C. A., & Southwick, S. M. (2005). Symptoms of posttraumatic stress disorder and borderline personality disorder in veterans of Operation Desert Storm. American Journal of Psychiatry, 162, 270-275. • Blaustein, M.E., Kinniburgh, K.M. (2010). Treating traumatic stress in children and adolescents: How to foster resilience through attachment, self-regulation , and competency. New York, Guilford. • Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73(5), 965-971. • Classen, C. C., Pain, C., Field, N. P., & Woods, P. (2006). Posttraumatic personality disorder: A reformulation of complex posttraumatic stress disorder and borderline personality disorder. Psychiatric Clinics of North America, 29, 87-112. • Courtois, C. (2012, February). New Guidelines for the treatment of complex trauma, Chevy Chase, Md. • Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., & Marks, J.J. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4). 245-258.

21. REFERENCES • Heller, D. P. (2012 February) The neurobiology of relationships: Crossing the bridge to secure attachment and to regain resilience and richness in relationships. Washington, DC • Hesse, E. (1999). The Adult Attachment Interview: Historical and current perspectives. In J. Cassidy & P.R. Shaver (Eds.), Handbook of attachment: Theory, research and clinical applications (pp.395 – 433). New York: Guilford Press. • Jankowski, M.K., Leitenberg, H., Henning, K., & Coffey, P. (2002). Parental caring as a possible buffer against sexual revictimization in young adult survivors of child sexual abuse. Journal of Traumatic Stress, 15(3), 235 – 244. • Johnson, D. M., Sheahan, T. C., & Chard, K. M. (2003). Personality disorders, coping strategies, and posttraumatic stress disorder in women with histories of childhood sexual abuse. Journal of Child Sexual Abuse, 12(2), 19-39. • Jonsson, P. V. (2009). Complex trauma, impact on development and possible solutions on an adolescent intensive care unit. Clinical Child Psychology and Psychiatry, 14, 437-454. • Luxenberg, T., Spinazzola, J., Hidalgo, J., Hunt, C., & van der Kolk, B. A. (2001a). Complex trauma and disorders of extreme stress (DESNOS) part one: Assessment. Directions in Psychiatry, 21(25), 373-393.

22. REFERENCES • Luxenberg, T., Spinazzola, J., Hidalgo, J., Hunt, C., & van der Kolk, B. A. (2001b). Complex trauma and disorders of extreme stress (DESNOS) part two: Treatment. Directions in Psychiatry, 21(26), 395-414. • Owens, G. P., & Chard, K. M. (2006). PTSD severity and cognitive reactions to trauma among a college sample: An exploratory study. Journal of Aggression, Maltreatment & Trauma, 13(2), 23-35. • Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication , self regulation. New York, W.W. Norton. • Renaud, E. F. (2008). The attachment characteristics of combat veterans with PTSD. Traumatology, 14(3), 1 – 12. • Schore, A. N. (2000). Attachment and the regulation of the right brain. Attachment & Human Development, 2(1), 23-47 • Singer, J. B. (2009). Cognitive-Behavioral therapy. In A. R. Roberts (Ed.), Social worker's desk reference (2nd ed., pp. 742-747). New York: Oxford • Sobel, A. A., Resick, P. A., Rabalais, A .E. (2009). The effect of Cognitive Processing Therapy on cognitions: Impact statement coding. Journal of Traumatic Stress 22(3), 205 – 211.

23. REFERENCES • Spitzer, C., Barnow, S., Wingenfeld, K., Rose, M., Lowe, B., & Grabe, H. J. (2009). Complex post-traumatic stress disorder in patients with somatization disorder. Australian and New Zealand Journal of Psychiatry, 43, 80-86. • van der Kolk, B. A., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (2005). Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress, 18(5), 389-399. • Wesselmann, D., & Potter, A. E. (2009). Change in adult attachment status following treatment with EMDR: Three case studies. Journal of EMDR Practice and Research, 3(3), 178-191. • Wolf, G. K., Reinhard, M., Cozolino, L. J., Caldwell, A., & Asamen, J. K. (2009). Neuropsychiatric symptoms of complex posttraumatic stress disorder: A preliminary Minnesota multiphasic personality inventory scale to identify adult survivors of childhood abuse. Psychological Trauma: Theory, Research, Practice, and Policy, 1(1), 49-64.