1 Attachment and the Impact of
Trauma
Sarah Lusardi, MSW Alison Morrisey, LCSW July 24, 2013 2 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. 3 Attachment
A deep and enduring emotional bond that connects one person to another across time and space.
1969)
(Ainsworth, 1973; Bowlby,
4 Attachment Theory
It started how late?!
Attachment theory did not evolve until1950’s with John
BOWLBY and then continued by Mary AINSWORTH in 1960’s
and 1970’s.
Primary conclusions….
Infants come into the world pre-programmed to form
attachments to others because it will help them to survive. 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
5 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. 6 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.
7 David Oppenheim, PhD
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. 8 David Oppenheim, PhD
Why Is Attachment Important?
Infants develop a ‘sense of self’ through relaEonships with other people. Influences ability to maintain commitments to work and/or school as older child and adult Informs child’s view and engagement in future relaEonships The quality of caregiver/child relaEonship has a profound effect on child’s social-­‐emoEonal development, personality formaEon and social competence. 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
Undiscriminating – baby responds to anyone (up to 3 months old) Differential responsiveness – baby knows and prefers
mother
(after 4 months to 9
months) Separation anxiety – Infant cries when attachment figure leaves and is
calmed when they returns (6/7 months to 10/18
months)
Active initiation – baby protests when attachment figure leaves
and actively pursues them by approaching,
following, and
greeting upon reunion (6/8 months to 24
Stranger anxiety – Infant crying when unfamiliar person months) approaches (8/9 months to 24
months)
10 Strange Situation Study
Mary AINSWORTH, 1978
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. 11 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.*
hBp://www.youtube.com/watch?v=s608077NtNI *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. 12 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.
13 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. hBp://www.youtube.com/watch?v=hsA5Sec6dAI 14 Secure or Insecure
What does it take?
Securely Attached
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
Insecurely Attached
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. 15 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.
16 Attachment Patterns
Secure
Attachment
•  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 17 Attachment Patterns
Anxious-Avoidant
Attachment
(Insecure)
•  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
18 Attachment Patterns
Anxious-Resistant
Attachment. OR
Ambivalent Attachment
(Insecure) •  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
19 Attachment Patterns
Disorganized
Attachment
(Insecure)
•  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
20 Reactive Attachment Disorder
RAD
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.
21 Circle of Security
22 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 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. 23 Serve and Return
Let’s play….
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. 24 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.” 25 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.* hBp://www.youtube.com/watch?
v=GeJAGozM6SA *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. 26 Stages of Emotional Reaction In Response to Separation and Loss
Protest: child is frightened and confused, screaming and anxiously looking for primary caregiver Despair: child is losing hope of being reunited; becomes depressed and disinterested in surroundings and food Detachment: child is indifferent to care from primary caregiver, does not connect with caregiver and no longer responds when caregiver leaves 27 Stress Types
A little bit of stress can be a good
thing.
Positive 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
Tolerable Stress
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. 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. 28 Trauma…What Is It?
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
29 Types of Trauma
TYPE 1
Single Incident
Single Exposure
Post-traumatic Growth
possible (PTG) Healing
TYPE 2
Chronic
TYPE 3
Complex Cumulative
Single type (like abuse)
repeated over a period
of time, or variety of
types
Repeatedly, cumulative,
and usually increases
over time
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,
Ex. Domestic violence,
serious accident, natural abuse, war
disaster
Ex. Ongoing physical or
sexual abuse, war, 30 captivity
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 31 Julie Cohen. ZERO TO THREE Domain Specific Signs of Trauma
In Infants and Toddlers
Attachment
Physical
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
Low self-esteem
focusing/
completing tasks
Difficulty
seeking help
Problems with
coordination/
balance
Problems with
communicating
needs
Sleep and eat
disturbances
Difficulty
anticipating
consequences
Shame Reenacting of
traumatic event
Learning
difficulties/
developmental
delays
Guilt
Pathological
self-soothing
practices
Problems with
language
development
Clingy, difficulty
with separations
Affect Regulation
Behavioral
Control
Cognition
Self-Concept
32 NaEonal Child TraumaEc Stress Network Long Term Impact of Trauma
Adverse Childhood Experiences (ACE) Study 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
33 What Protects a Child During
Trauma?
34 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
Where
have of
weself
seen these factors
before?….Secure Attachment! 35 Building Resiliency
Resiliency is the ability to steer through serious life challenges and find ways to bounce back and thrive. •  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
36 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
37 Luthar & Zigler (1991)
How Can Caregivers Help?
Ensure health, safety and good
nutrition.
Encourage safe exploration and
play.
Help children feel safe and secure.
Establish routines.
‘Serve and Return’ with them
consistently.
Really listen to children and
respond to their cues, verbal and
non-verbal.
Talk, read and sing to and have
conversations with child.
Be a consistent, responsive and loving
caregiver.
Minimize stress to keep Cortisol
levels low.
Be sensitive around transitions.
Be responsive to crying.
Remove physical threats.
Look through trauma lenses
when engaging with child
Seek professional help when
needed.
38 Therapeutic Interventions
•  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
39 Resources and Referrals
*When referring, ask for a clinician with early childhood expertise and
training
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
40 What’s Coming Up?
Session 4 IECMH Best PracEces – EffecEve CollaboraEon and SupporEng Resiliency Session 5 Case Conferencing and CollaboraEon Joint Session with Child Welfare staff 41 The Impact of Trauma and
The Importance of Attachment
Contact us! Sarah Lusardi, MSW [email protected]; 413-­‐586-­‐4998 x 107 Alison Morrisey, LCSW [email protected]; 413-­‐586-­‐4998 x105 42