Marcialee Ledbetter, M.D. Board Certified, General, Child

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Disorders of Attachment

• Marcialee Ledbetter, M.D.
• Board Certified, General, Child, and Adolescent
  Psychiatry
• Medical Director
• Riverside Specialty Programs
• Eagle Creek Native American Program
• Grey McKellar, MSW, LCSW
• Program Director, Riverside Specialty Program
• Therapist, ACE Unit
• Shadow Mountain Behavioral Health System
• Tulsa, Oklahoma

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Part I

• The Development of Attachment

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• If one does not understand a person, one tends
  to regard him as a fool.
• - C.G. Jung

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A Definition of Attachment

• The strong affectional/emotional bond that
  develops and exists between individuals
  classically between the developing child and his
  or her caretaker.

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Developmental Stages - Bowlby

• 0 8-12 weeks Preattachment
• Behaviors
• Primitive
• Orienting
• Signaling
• 3 to 7 months Attachment in the Making
• Discriminates between familiar and unfamiliar
• Differential responses to figures

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Developmental Stages - Bowlby

• 7 to 36 months Attachment
• 7 to 24 months
• Signs of distress at separation
• Might need to cling to parent at return
• 24 months
• More proactive in interacting with others,
  manipulating the environment

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Developmental Stages - Mahler

• 0-1 month Autistic Phase
• homeostasis
• 1- 4 to 5 months Symbiotic Phase
• Social smile at 8 weeks
• Awareness of caretaker but not yet differentiated

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Developmental Stages - Mahler

• 5 to 36 months Separation-Differentiation Phase
• 5 to 10 months Differentiation
• Stranger anxiety
• 10 to 16 months Practicing
• Separation anxiety
• 16 to 24 months Rapprochement
• at the threshold
• 24-46 months Consolidation
• Object constancy - parent will return

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Factors in Attachment

• Infant
• Genetic
• Temperament - Risk for Mental Illness
• Communication abilities
• Health
• Caretaker
• Genetic
• Temperament - Risk for Mental Illness Level of
  Cognition
• Responsiveness
• Health
• Strengths/weaknesses

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Factors in Attachment

• Environment
• Home
• Food/Water/Shelter
• Safety/Security
• Resources
• Financial
• Supports for parents
• Number of caregivers

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Part II

• Characteristics of Attachment Problems

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Maslows Hierarchy of Needs

• Need for
• Self Actualization
• Need for Self Esteem
• Need for love and affection
• Need for safety and security
• Need for food, water, air, and protection from
  elements

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Circle of Security Parent Attending to the
Childs Needs
I need you to
I need you to

• Watch over me
• Help me
• Delight in me
• Enjoy with me

Support My Exploration
I need you to
I need you to
Welcome My Coming To You

• Protect me
• Comfort me
• Delight in me
• Organize my feelings

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Attachment Types Mary Ainsworth

• Secure
• Insecure
• Anxious/Ambivalent
• Resistant
• Avoidant
• Disrupted

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• If you don't ask the right questions, you don't
  get the right answers. A question asked in the
  right way often points to its own answer. Asking
  questions is the ABC of diagnosis. Only the
  inquiring mind solves problems.
• A good problem statement often includes (a)
  what is known, (b) what is unknown, and (c) what
  is sought.
• - Edward Hodnett

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• as we know, there are known knowns there are
  things we know we know. We also know there are
  known unknowns that is to say we know there are
  some things we do not know. But there are also
  unknown unknowns -- the ones we don't know we
  don't know.
• -Donald Rumsfeld

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DSM-IV Criteria for RAD

• Markedly disturbed and developmentally
  inappropriate social relatedness in most
  contexts, beginning before age 5 years, as
  evidenced by either
• Persistent failure to initiate or respond in a
  developmentally appropriate fashion to most
  social interactions, as manifest by excessively
  inhibited, hypervigilant, or highly ambivalent
  and contradictory responses (Inhibited type)
• Diffuse attachments as manifest by indiscriminate
  sociability w/ marked inability to exhibit
  appropriate selective attachments (Disinhibited
  type)

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DSM-IV Criteria for RAD

• The disturbance is not accounted for solely by
  developmental delay and does not meet criteria
  for a Pervasive Developmental Disorder
• Pathogenic care as evidenced by a least one of
  the following
• Persistent disregard of the childs basic
  emotional needs for comfort, stimulations, and
  affection
• Persistent disregard of the childs basic
  physical needs
• Repeated changes of primary caregiver that
  prevent formation of stable attachments
• A presumption that the pathogenic care is
  responsible for the disturbed behavior

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Whats in a Name

• DSM IV Reactive Attachment Disorder
• Attachment Issues
• Attachment Problems
• Neurologic Sequelae
• Intelligence
• Motor Skills
• Language Skills
• Self-Regulatory Skills
• Mental Illness

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Attachment Issues

• Development of Relationships
• Mistrust Manipulation - Fear
• Low Frustration Tolerance
• Aggression - Reactivity
• Emotional Immaturity/ Personality Development
• Lack of Empathy
• Narcissism

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Neurologic Sequelae

• Intelligence
• Developmental Tasks/Self Regulatory Skills
• Speech/Language
• Motor
• Executive Function
• ADLs including sleeping, eating, grooming

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Co-Morbid Conditions

• Genetic vs. Environmental vs. Both
• ADHD
• Mood Disorders
• Anxiety Disorders
• Psychotic Disorders
• Fetal Alcohol Syndrome
• Other Malnutrition, other substances

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Whats in a Name?

• General Health
• There is a chain that runs from the behaviour
  of cells and molecules to the health of
  populations, and back again, a chain in which the
  past and the present social environments of
  individuals, and their perceptions of those
  environments, constitute a key set of links. No
  one would pretend that the chain is fully
  understood, or is likely to be for a considerable
  time to come. But the research evidence currently
  available no longer permits anyone to deny its
  existence.
• Why Are Some People Healthy and Others Not?
  Robert Evans, Morris Barrer, and Theodore Marmor,
  1994.

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ACE Study Questionnaire

• Emotional Abuse
• Physical Abuse
• Sexual Abuse
• Felt unloved
• Neglect
• Parents Divorced or separated
• Observe Parent being abused
• Caretaker w/ substance abuse problems
• Caretaker w/ mental illness
• Caretaker to prison

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Whats in a Name?

• ACE Studies Turning Gold into Lead

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Whats in a Name?

• ACE Studies Turning Gold into Lead

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Whats in a Name?

• Proposed Categories/DSM V
• Developmental Trauma Disorder
• Complex Post Traumatic Stress Disorder
• Disorders of Extreme Stress, not otherwise
  specified

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Part III

• Evaluation of Attachment Problems

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Nature via Nurture From Environment to Brain
Development to Behavior
Nature via Nurture From Environment to Brain
Development to Behavior
PUBERTY/ CHILDHOOD CHILDHOOD/ EARLY
CHILDHOOD EARLY CHILDHOOD/ INFANCY 6
MONTHS/ 3rd TRIMESTER
CORTEX LIMBIC BASAL GANGLIA MIDBRAIN/ BRAINSTEM
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Nature via Nurture From Environment to Brain
Development to Behavior
MODULATION
Plasticity Complexity
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Evaluation of Attachment Problems

• Present Illness Home/School/Social
• Social History Careful Timeline
• Development Communication/Motor/Social/Adaptive
• Family Medical and Psychiatric Illness
• Genogram biological family/current living
  situation
• Treatment Psychotherapy/Medication/Targeted
  Therapies (e.g. speech/language)

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Evaluation of Attachment Problems Observation

• Child
• Mental Status Exam
• Developmental Skills including play skills
• Interaction with Others
• Parent
• Child/Parent Interactions
• May include Ainsworth Strange Situation or
  similar protocol

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Evaluation of Attachment Problems and Co-morbid
Disorders Rating Scales

• Child
• Child Behavior Checklist
• More specific scales for disorder
• ADHD Rating Scale
• Trauma Symptom Checklist for Children
• Randolph Attachment Disorder Questionnaire (?)
• Parent
• Personality MMPI, SCL-90
• Adult Attachment Interview
• Parenting Stress Index

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Part IV

• Interventions for Disorders of Attachment

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Bruce Perry Neurodevelopmental Model for
Treatment
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Early Intervention

• Nurture these children. -They need to be held,
  rocked, and cuddled
• Try to understand the behaviors before punishment
  or consequences.-A punitive approach to problems
  (and many others) will not help the child mature.
  Instead, punishment may actually increase the
  child's sense of insecurity, distress.
• Interact with these children based on emotional
  age. - If they are tearful, frustrated, or
  overwhelmed (emotionally age two), treat them as
  if they were that age. This is not the time to
  use complex verbal arguments about the
  consequences of inappropriate behavior.

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Early Intervention

• Be consistent, predictable and repetitive. - Very
  sensitive to changes in schedule, transitions,
  surprises, chaotic social situations, and, in
  general, any new situation.
• Model and teach appropriate social behaviors. -
  Narrate for the child what you are doing and why.
  
• Listen to and talk with these children. - One of
  the most helpful things to do is just stop, sit,
  listen, and play with these children

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Early Intervention

• Have realistic expectations of these children.- A
  comprehensive evaluation by skilled clinicians
  can be very helpful in beginning to define the
  skill areas of a child, as well as the areas
  where progress will be slower.
• Be patient with the child's progress and with
  yourself. - Progress will be slow. Don't be hard
  on yourself.
• Take care of yourself

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Riverside ACE Program

• Ages 4 to 11 (next year increase to 12)
• History of abuse and or neglect
• Serious emotional and behavioral problems
• Dangerousness to self and/or others
• History of no response/poor response to treatment
  including Trauma based treatment
• Children sent out of state for treatment

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Riverside ACE Program

• Theory Dyadic Developmental Psychotherapy
• PLACE Playful Loving Accepting Curious -
  Empathic
• PACE Playful Accepting Curious - Empathic
• Central Principles
• Develop attunement
• Develop primary secondary intersubjectivity
• Develop an autobiographical narrative
• Integrate past trauma into the narrative expose
  operation of internal working models and how
  these distort current relationships

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Riverside ACE Program

• the magic happens on the floor
• Milieu Rules
• Child needs to ask for everything he or she wants
• Know where the child is at all times
• No hands on without permission
• Key Elements
• Dyadic Relationships NURTURING
• Multidisciplinary/Communication
• Ongoing Education
• Parent Involvement
• Relationship Based

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Riverside ACE Program

• Goals
• Help the child to
• Develop trust
• Regulate affect
• Create a coherent narrative
• Help the parent to
• Understand their childs struggles
• Understand their part in development of a
  relationship
• Understand their own strengths and weaknesses and
  how that relates to their parenting style and
  relationship with their child

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Riverside ACE Program

• Stages of Treatment
• Stage I Trust of Care learning about the child
• Dependency on a healthy caregiver
• Stage II Trust of Control changing the child
• Nurturing discipline and control
• Stage III Trust of Self reintegrating into the
  family
• Responsibility given back to the child

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Riverside ACE Program

• Theraplay and Activities for Patients
• Structure Engaging Nurturing Challenging
• Collaborative Games
• Building with Legos art projects
• Cooperative Activities
• Board Games
• Relationship Building Activities
• Examples vary depending on age of child
  Patty-Cake, Hand-Clapping Games, Trampoline

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Intervention Strategies Targeted Therapies

• Speech and Language Development
• Language Development
• DIR Floor Time
• Motor Skills
• Sports
• Physical Therapy
• Occupational Therapy
• Sensory Integration
• Examples Weighted blanket, chewing gum, swinging

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Bibliography

• http//www.childtrauma.com, Bruce Perry
• Creating Capacity for Attachment Dyadic
  Developmental Psychotherapy in the Treatment of
  Trauma-Attachment Disorders, Arthur
  Becker-Weidman, Deborah Shell, Editors, Wood N
  Barnes Publishing, 2005
• Relationship of Childhood Abuse and Household
  Dysfunction to Many of the Leading Causes of
  Death in Adults The Adverse Childhood
  Experiences (ACE) Study, Vincent J Felliti, et
  al, American Journal of Preventative Medicine
  Volume 14( 4), Pages 245-258 (May 1998)

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Bibliography

• "Editorial comments complex developmental
  trauma". Journal of Traumatic Stress van der
  Kolk, B.A. Courtois, C.A. (2005). 18, 385-388.
• "Disorders of extreme stress the empirical
  foundation of a complex adaptation to trauma".
  van der Kolk, B.A., et al (2005),Journal of
  Traumatic Stress 18, 389-399.
• Diagnostic and Statistical Manual of Mental
  Disorders, Fourth Edition (DSM-IV), American
  Psychiatric Association, 2000.

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Bibliography

• Theraplay Helping Parents and Children Build
  Better Relationships Through Attachment-Based
  Play, Second Edition, Jernberg, AM, Booth PB,
  Jossey-Bass Publishers, 2001.
• The Developing Mind How Relationships and The
  Brain Interact to Shape Who We Are, Daniel J
  Siegel, The Guilford Press, New York, 1999.
• Treating Attachment Disorders From Theory to
  Therapy, Karl Heinz Brisch, The Guilford Press,
  New York, 1999.

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Bibliography

• Practice Parameter for the Assessment and
  Treatment of Children and Adolescents with
  Reactive Attachment Disorder of Infancy and Early
  Childhood, JAACAP, Volume 44 (11), 2005.
• Building Bridges through Sensory Integration, 2nd
  Edition, Ellen Yack, et al, Future Horizons, Inc,
  2003.
• The Out-of-Sync Child, 2nd Edition, Carol Stock
  Kranowitz, MA, Perigee, 2005.

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Bibliography

• http//www.circleofsecurity.org/
• Parenting Stress Index, 3rd Ed. (PSI)Richard R.
  Abidin, EdD , Psychological Assessment Resources,
  Inc. at http//www3.parinc.com
• Nature via Nurture Genes, Experience, and What
  Makes Us Human, Matt Ridley, HarperCollins, New
  York, 2003

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• Healing is a matter of time, but it is also a
  matter of opportunity.
• -Hippocrates