Keeping Attachment Intact Following Trauma

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Keeping Attachment Intact Following Trauma

• Douglas Goldsmith, Ph.D.
• Executive Director
• The Childrens 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

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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)

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Secure vs Insecure Attachment

• The classifications Secure vs Insecure
  Reflect the infants apparent perception of the
  availability of the caregiver if a need for
  comfort or protection should arise, and the
  organization of the infants responses to the
  caregiver in light of those perceptions of
  availability.
• 
  Weinfield et al (1999)

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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)

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Secure Attachment

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

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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 Im held I feel warm, safe, and comforted
• Results in a relaxed state so that one can,
  again, begin to explore
  

• Holmes (1993)

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Secure Attachment

• 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)

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Anxious Attachment

• Maintain constant low levels of anxiety about the
  caregivers availability
• Unable to explore the environment without worry
• Fail to achieve confidence in themselves and
  mastery of their enviroment
• 
  Weinfield et al (1999)

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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

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Childrens Response to Trauma

• Loss of sense of basic trust
• Loss of security
• Destabilized Secure Base
• Compromised emotional development

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Impact of Parental Depression

• Children
• Show more depressed affect
• Show more behavior problems
• Maladaptive interactions with parents
• Field (1987, 1995)

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Impact of Parental Anxiety

• Unable to hear their childrens distress
• Withdraw to protect themselves emotionally
• Difficulty tolerating childrens anxiety and
  aggression
• Osofsky Fenichel, (1994, 1996, 2000)

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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

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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)

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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)

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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)

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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)

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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)

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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)

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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

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The Case of Sara

• Allegations of neglect arise
• Sara is removed from the home at the age of 10
  months

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The Case of Sara

• Shelter home for four days
• Second foster home for one week
• Third foster home for eight
• weeks
• Adoptive home

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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

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The Case of Sara

• At the age of 15 months Sara is responding well
  to her new environment
• First adoptive family hasnt seen her for 6
  months and want her returned to their care

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The Case of Sara

• Should she return?
• Who are the psychological parents?
• Does she remember her first adoptive parents?
• Shes so young that she wont remember anything
  and can be returned without distress
• Sara is a resilient child

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The Case of Sara

• The internal working model viewing the world
  through Saras eyes
• Assessing risk
• Could reunion reactivate feelings of loss?
• Utilization of second adoptive parents as a
  secure base
• Impact of no contact

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Factors Favoring Saras 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

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Factors AgainstSaras 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

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Factors Against Saras 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

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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

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Implications for Caseworkers

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

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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

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Observation of Parent-Child Relationship

• Observe proximity seeking behaviors watch eye
  contact and social relatedness
• Observe parental sensitivity and insightfulness
  to childs cues
• Who does child seek out when frustrated or
  frightened
• Use doll play to assess attachment hierarchy

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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

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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

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Intervention

• Increase structure to manage acting out behaviors
• Remind children that rules havent changed
• Continue with consequences
• Increase communication and help child understand
  their response to trauma

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Intervention

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

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Intervention

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