Attachment disorders


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Attachment disorders

  1. 1. Attachment Disorders Harvey Tuck Bendigo CAMHS
  2. 2. Attachment <ul><li>Is an instinctive system in the brain that evolved to ensure infant safety and survival. </li></ul><ul><li>Early attachment occurs in a unique way. </li></ul><ul><li>The ‘attuned’ primary caregiver will observe and follow the lead of the infant. </li></ul><ul><li>Attachment is essential for the foundation of a healthy personality. </li></ul>
  3. 3. When there is Secure Attachment <ul><li>The adult aligns his/her own internal state with that of the infant or child – and communicates this alignment in non-verbal ways that the child understands. </li></ul><ul><li>This “communication” forms a bond of trust that makes the infant feel that he/she is felt, known and respected. </li></ul>
  4. 4. When there is Secure Attachment <ul><li>Through this mutually attuned interaction, the infant learns to attain balance in his/her body, emotions and states of mind. </li></ul><ul><li>The comfort, pleasure and mutuality of the attuned interaction creates a sense of safety within the infant and inspires interpersonal connection to others. </li></ul>
  5. 5. Secure Attachment and Development <ul><li>Attachment experience directly influences the development of children and is directly responsible for activating or not activating their genetic potential. </li></ul><ul><li>Establishes the basis on which the child will form relationships with others; his/her sense of security about exploring the world; </li></ul>
  6. 6. Secure Attachment <ul><li>Establishes his/her resilience to stress </li></ul><ul><li>Assists ability to balance his/her emotions </li></ul><ul><li>Helps makes sense of his/her life </li></ul><ul><li>Helps to create meaningful interpersonal relationships in the future. </li></ul>
  7. 7. Resilience - Attributes <ul><li>Social Competence – Communication skills, sense of humour, responsive to others </li></ul><ul><li>Problem-solving skills – Planning, help seeking, critical & creative thinking </li></ul><ul><li>Autonomy - secure sense of identity, self worth, ability to cope </li></ul><ul><li>Sense of Purpose - hope for future, personal goals & values, connectedness </li></ul>
  8. 8. Resilience & Diversity <ul><li>Cultural pride </li></ul><ul><li>Connectedness - caring, participation, achievement </li></ul><ul><li>Belonging </li></ul><ul><li>Hope for future </li></ul><ul><li>Acceptance & respect </li></ul>
  9. 9. Resilience Building <ul><li>Connect to family, friends, school </li></ul><ul><li>Relationships - caring adult, role models </li></ul><ul><li>Self esteem </li></ul><ul><li>Belief in own ability to cope </li></ul><ul><li>Sense of control </li></ul><ul><li>Developing skills & competence </li></ul>
  10. 10. Resilience – Personal Strengths Handout <ul><li>Social Competence vs Social Estrangement </li></ul><ul><li>Problem Solving vs Stuckness </li></ul><ul><li>Autonomy vs Powerlessness </li></ul><ul><li>Sense of Purpose vs Meaninglessness </li></ul>
  11. 11. Does Secure Attachment need to be perfect? <ul><li>If communication is secure at least a third of the time or more, that is enough to support a secure relationship. </li></ul><ul><li>Repair is an important part of the attachment process - not being put off by disruptions to closeness. </li></ul><ul><li>The primary caregiver (who sets the limits) needs to initiate repair as soon as the child initiates a desire for reconnection. </li></ul>
  12. 12. What is an Attachment Disorder? <ul><li>A condition in which individuals have difficulty forming loving, lasting, intimate relationships. </li></ul><ul><li>They typically fail to develop a conscience and do not learn how to trust. </li></ul>
  13. 13. What causes insecure attachment and attachment disorders? <ul><li>Physical neglect. </li></ul><ul><li>Emotional neglect. </li></ul><ul><li>Abuse. </li></ul><ul><li>Separation form primary caregiver. </li></ul><ul><li>Changes in primary caregiver. </li></ul><ul><li>Frequent moves or placements. </li></ul><ul><li>Traumatic experiences. </li></ul><ul><li>Maternal depression ( Carer Unavailability ) </li></ul>
  14. 14. What causes insecure attachment and attachment disorders? <ul><li>Undiagnosed painful illnesses such as colic, ear infections, etc. </li></ul><ul><li>Lack of attunement or harmony between mother and child. </li></ul><ul><li>Young or inexperienced mother with limited parenting skills. </li></ul><ul><li>Maternal addiction to drugs or alcohol. </li></ul>
  15. 15. Implications for Brain Development <ul><li>If the attachment process is disrupted, the child’s brain will develop stronger neural pathways focussed on meeting his/her day-to-day survival. </li></ul><ul><li>The pathways that help to regulate and control their emotions and an awareness of others emotions are not well developed. </li></ul>
  16. 16. Implications for Brain Development <ul><li>The child lives in a persistent state of hyperarousal or dissociation – anticipating threats around every corner. </li></ul><ul><li>Their ability to benefit from social, emotional and cognitive experiences may be impaired. </li></ul><ul><li>The child may not be functioning at their chronological age in terms of their physical, social, emotional and cognitive skills. </li></ul>
  17. 17. What are the signs & symptoms of insecure attachment? <ul><li>Symptoms can include the following- </li></ul><ul><li>Low self esteem </li></ul><ul><li>Needy, clingy or pseudo-independent behaviour. </li></ul><ul><li>Inability to deal with stress and adversity. </li></ul><ul><li>Lack of self control. </li></ul><ul><li>Inability to develop and maintain friendships. </li></ul><ul><li>Alienation from and opposition to parents, caregivers and other authority figures. </li></ul>
  18. 18. What are the signs & symptoms of insecure attachment? <ul><li>Anti-social attitudes and behaviours. </li></ul><ul><li>Aggression and violence. </li></ul><ul><li>Difficulty with genuine trust, intimacy and affection. </li></ul><ul><li>Negative, hopeless, pessimistic view of self, family and society. </li></ul><ul><li>Lack of empathy, compassion and remorse. </li></ul><ul><li>Behavioral and academic problems at school. </li></ul><ul><li>Speech and language problems. </li></ul>
  19. 19. What are the signs & symptoms of insecure attachment? <ul><li>Incessant chatter and questions. </li></ul><ul><li>Difficulty learning. </li></ul><ul><li>Depression. </li></ul><ul><li>Apathy. </li></ul><ul><li>Susceptibility to chronic illness. </li></ul><ul><li>Obsession with food: hordes, gorges, refuses to eat, eats strange things, hides food. </li></ul><ul><li>Repetition of cycle of maltreatment and attachment disorder in their own children when they reach adulthood. </li></ul>
  20. 20. What is Reactive Attachment Disorder (RAD) or Disorganized Attachment Disorder? <ul><li>It is a clinically recognized severe insecure attachment. </li></ul><ul><li>Children with RAD are so neurologically disrupted that they cannot attach to a primary caregiver or go through normal developmental processes. </li></ul><ul><li>These children have no consistent or organized strategy for responding to stress as the person that should have made them feel safe is usually frightening (e.g. abusive parent) or is communicating fright (e.g. parents being abused). </li></ul>
  21. 21. What is Reactive Attachment Disorder (RAD) or Disorganized Attachment Disorder? <ul><li>They usually come from homes characterized by child maltreatment, by parental depression, bi-polar disorder, substance abuse and/or by unresolved trauma, grief or loss. </li></ul><ul><li>These children cannot establish positive relationships with other people. </li></ul><ul><li>Many are misdiagnosed as having severe emotional and behavioral disturbances e.g. ADHD. </li></ul>
  22. 22. Why do children use defence mechanisms? <ul><li>To protect the child from overwhelming and intolerable feelings and memories of traumatic experiences. </li></ul><ul><li>May be seen via idealization, projection, denial, displacement, dissociation, splitting. </li></ul><ul><li>Over idealizing an abusive or neglectful mother allows the child to avoid and deny the painful reality that she/he provided insufficient nurturance, love and protection. </li></ul>
  23. 23. Why do children use defence mechanisms? <ul><li>Denial – saves the child from having to experience the grief and rage that accompanies facing the truth. </li></ul><ul><li>Dissociation – is an automatic response that protects the child during trauma. </li></ul><ul><li>Displacement – enables the child to project onto carers or workers the feelings and perceptions that he/she actually has toward maltreating biological parents or others. </li></ul>
  24. 24. How is inadequate attachment repaired? <ul><li>The learning that accompanies new experiences can alter neural connections in the brain. </li></ul><ul><li>Relationships with relatives, teachers, welfare, support and childcare providers can provide an important source of connection and strength for the child’s developing mind. </li></ul>
  25. 25. Corrective Attachment Therapy – Principles of Treatment <ul><li>The therapy process recapitulates the physical, emotional and interpersonal characteristics of secure parent-child attachment. </li></ul><ul><li>That is, the ingredients found in parent-child relationships leading to secure attachment, must also be available in the therapist- child relationship. </li></ul>
  26. 26. Corrective Attachment Therapy - STRUCTURE <ul><li>The worker provides a framework with limits, rules and boundaries. The structure is consistent and predictable, yet flexible, and changes in accordance with the child’s developmental needs. </li></ul><ul><li>Contracts are developed that define the responsibilities of the child and the worker – and the goals they hope to achieve. </li></ul>
  27. 27. Corrective Attachment Therapy - ATTUNEMENT <ul><li>The worker is sensitively attuned to the child’s needs, feelings, internal working model. </li></ul><ul><li>Based on a precise understanding of how the child thinks and feels, the worker provides the message “ I know what you need in order to feel safe, and I will meet your needs”. For instance it is understood that the child’s hostile and controlling demeanor is actually a defensive strategy designed to protect him/her from feelings of vulnerability, insecurity & fear. </li></ul>
  28. 28. Corrective Attachment Therapy - EMPATHY <ul><li>The worker needs to convey a heartfelt level of caring and compassion. The worker needs to remain proactive, empathic, warm and caring – rather than reacting negatively to the child’s overly hostile or distancing behaviour. </li></ul><ul><li>The message conveyed is “How sad those terrible things happened to you. I am sorry that you were treated that way.” </li></ul>
  29. 29. Corrective Attachment Therapy – POSITIVE EFFECT <ul><li>The worker needs to maintain a positive demeanor – particularly when the child is acting out e.g. verbal abuse. </li></ul><ul><li>This prevents the re-enactment of dysfunctional patterns, such as when the child directly or unconsciously ‘invites’ a caregiver to be rejecting, angry or abusive. </li></ul><ul><li>The message conveyed is “I will not allow you to control our relationship in unhealthy and destructive ways”. </li></ul>
  30. 30. Corrective Attachment Therapy – SUPPORT <ul><li>The worker needs to provide a ‘scaffolding’ of support tailored to the developmental needs and capabilities of the child. </li></ul><ul><li>During initial work with the child, the worker emphasizes rules, expectations and natural consequences. </li></ul><ul><li>As the work progresses, the focus shifts to reinforcing and celebrating the child’s independent achievements. </li></ul>
  31. 31. Corrective Attachment Therapy – RECIPROCITY <ul><li>A positive reciprocal relationship is one in which there is mutual influence and regulation. </li></ul><ul><li>The securely attached child achieves a ‘goal orientated partnership’ with his or her parents, characterized by a sharing of control, ideas, values, feelings, plans and goals. </li></ul><ul><li>This alliance is usually achieved by age 4 – if there has been successful completion of earlier stages of attachment. </li></ul>
  32. 32. Corrective Attachment Therapy – LOVE <ul><li>Secure attachment is synonymous with love. </li></ul><ul><li>Children with attachment disorder are generally incapable of experiencing and demonstrating love towards themselves and others. </li></ul><ul><li>Attachment therapy provides that relationship context, and in doing so, guides the child to a place where love is suddenly an option. </li></ul><ul><li>Children will only feel safe in experiencing and expressing love if their parent/ primary care giver is ‘available’ to receive that love. </li></ul>
  33. 33. TREATMENT <ul><li>Revisit </li></ul><ul><li>Revise </li></ul><ul><li>Emotional Change and Healing </li></ul><ul><li>Compliance </li></ul><ul><li>Trust </li></ul><ul><li>Prosocial Coping Skills </li></ul><ul><li>Revitalize </li></ul>
  34. 34. Treatment – REVIST <ul><li>1. Gain an understanding of the young person’s personal understanding and interpretation of what has happened in their life, their emotional and somatic reactions, their associated imagery and memory and the responses of significant others. </li></ul><ul><li>Through doing this the therapist gains valuable diagnostic information and understanding of the child’s internal working model, emotional responses and interpersonal patterns. </li></ul>
  35. 35. Treatment – REVISIT <ul><li>The belief system of the child with attachment disorder is orientated negatively toward self :“I am bad, unworthy of love”. </li></ul><ul><li>Toward caregivers “ They are untrustworthy, threatening, unloving”. </li></ul><ul><li>Towards humanity “People are basically bad, life is not worth living”. </li></ul>
  36. 36. Treatment – REVISIT <ul><li>There is a universal belief in the value of “truth telling” as part of the healing ritual. </li></ul><ul><li>As the child shares his/her story honestly for the first time, a meaningful connection is created. </li></ul><ul><li>Telling and retelling the story desensitizes the negative emotional charge associated with traumatic events. </li></ul><ul><li>The acceptance and validation received from the therapist in the ‘in arms’ experience also reduces the child’s shame and guilt. </li></ul>
  37. 37. Treatment Goals– REVISE <ul><li>Developing secure attachment patterns that were never previously established. </li></ul><ul><li>Revising disturbed attachment patterns that were created early in life. </li></ul><ul><li>Construct new interpretations. </li></ul><ul><li>Deal effectively with emotions. </li></ul><ul><li>Develop secure attachments. </li></ul><ul><li>Learn prosocial coping skills. </li></ul>
  38. 38. Treatment – REVISE <ul><li>Create mastery over prior trauma and loss. </li></ul><ul><li>Develop a positive sense of self. </li></ul><ul><li>Enhance self regulation. </li></ul><ul><li>Address family systems issues (family of origin work with parents; marital issues; parenting skills; mobilizing community resources). </li></ul>
  39. 39. Treatment – REVISE <ul><li>MODIFICATION OF CHILD’S NEGATIVE WORKING MODEL & MALADAPTIVE CORE BELIEFS – Identify and acknowledge beliefs; challenge negative working model. The therapist also acknowledges, confronts and challenges defence mechanisms. </li></ul>
  40. 40. Treatment – EMOTIONAL CHANGE and HEALING <ul><li>Assist the child to experience, process and express emotions in a constructive way. </li></ul><ul><li>The therapist models constructive expressions of his/her own affect – that is, does not react to the child’s emotions with anger, anxiety or shock. </li></ul><ul><li>The child learns to internalize acceptance, empathy and support from the therapist. </li></ul>
  41. 41. Treatment - EMOTIONAL CHANGE and HEALING <ul><li>Also involves relaxation strategies, anxiety mismanagement strategies and introducing these to daily routine of the young person e.g. physical activity / exercise; breathing techniques; visualization techniques. </li></ul><ul><li>Sensory Integration strategies can also be helpful. </li></ul><ul><li>TENSION – DISCHARGE – RELAXATION CYCLE – Therapist tries to replicate this – which is similar to the first year of life attachment cycle. </li></ul>
  42. 42. Tension-Discharge-Relaxation Cycle <ul><li>Discharge (Physical release, </li></ul><ul><li>emotional release, sobbing) </li></ul><ul><li>Tension Relaxation (calm </li></ul><ul><li>Increases defenses reduced </li></ul><ul><li>vulnerable, open </li></ul><ul><li>to attachment, </li></ul><ul><li>healing and change). </li></ul>
  43. 43. EMOTIONAL CHANGE and HEALING – Grief and Loss <ul><li>COPING WITH GRIEF & LOSS – assisting the child to cope with the many losses they may have experienced e.g. primary care giver, foster parents. (Use of psychodramatic re-enactment, photos, life stories). </li></ul>
  44. 44. Treatment - COMPLIANCE <ul><li>Children with attachment disorders did not develop basic compliance with authority figures – therefore become ‘bossy’ and engage in power struggles in relationships. </li></ul><ul><li>The attachment therapist provides the conditions associated with early phases of attachment (nurturance, structure, support and attunement) in order to help the child learn basic compliance to authority. </li></ul><ul><li>The therapist must be willing and able to take control of a child who is personally and interpersonally out of control. </li></ul>
  45. 45. Treatment – COMPLIANCE - TRUST <ul><li>Desensitization occurs when the child’s level of anxiety decreases as he or she experiences letting go of control with a safe adult. </li></ul><ul><li>TRUST- assist the child in acknowledging their lack of trust. </li></ul><ul><li>This allows honesty and vulnerability with the therapist in the safety of the ‘holding nurturing context’. </li></ul><ul><li>This is the beginning of the initial stage of trust development. </li></ul>
  46. 46. Treatment – PROSOCIAL COPING SKILLS <ul><li>Help the child develop these skills so that they can function successfully in families & in society. </li></ul><ul><li>This involves (i) Communication Skills </li></ul><ul><li>(ii) Self Control (iii) Problem Solving. </li></ul><ul><li>May involve modelling from peers and adults, play therapy, role play, analysis of media material. </li></ul>
  47. 47. Treatment - Revitalize <ul><li>The goal of this stage is to move towards the present and the future. </li></ul><ul><li>Redefining Self – a child who has successfully dealt with prior attachment trauma is able to develop a new and increasingly more positive identity. </li></ul><ul><li>People and events from the past are placed in perspective, and the child is able to function without feeling overwhelmed or devastated by traumatic memories. </li></ul>
  48. 48. Treatment - Revitalize <ul><li>Helplessness and isolation, the core experiences of the old self, are replaced by empowerment and connection with others. </li></ul><ul><li>The child is capable of trust, affection and empathy and reciprocity in his/her relationships with family and others. </li></ul><ul><li>Forgiveness occurs as the child is no longer controlled by negative emotions. </li></ul><ul><li>He or she develops a stable sense of self. </li></ul>
  49. 49. Treatment / Intervention Tips <ul><li>Traditional techniques that aim to change or modify specific behaviours are notoriously unsuccessful with children who have attachment disorders. </li></ul><ul><li>It is more effective to deflect attention away from specific negative behaviours – view the problem behaviour as the child’s way of keeping others at a distance – and recognize that the true problem is fear of intimacy. </li></ul>
  50. 50. Closeness as Non- Negotiable <ul><li>When the child is having a hard time, he/she needs to be close, so the caregiver can help – if the child is having a good day – they also need to be close, so as to not miss out on the fun. </li></ul><ul><li>Non-negotiable closeness implies substituting nurture and supportive control techniques in place of punishment. </li></ul><ul><li>Common interventions such as isolation, seclusion or the familiar ‘go to your room’ are counterproductive as… </li></ul>
  51. 51. Closeness as Non- Negotiable <ul><li>… these children have what is called “reversal of learning” in which closeness is scary and distance is safe. </li></ul><ul><li>Therefore isolation has exactly the opposite of its intended effect : it is gratifying or rewarding to the child. </li></ul>
  52. 52. Working with Adolescents <ul><li>Developing trust is still a crucial issue when working with issues of attachment. </li></ul><ul><li>It becomes complicated because part of the ‘normal’ process of adolescence involves moving beyond one’s initial attachment to parents and caregivers. </li></ul><ul><li>Often substance abuse becomes their way of dealing with the pain of attachment disorder. </li></ul>
  53. 53. Working with Adolescents <ul><li>Another way adolescents may cope with an attachment disorder is to build a sense of trust and relationship with their peers through the strong bonds formed within a gang. </li></ul><ul><li>Older adolescents are benefited by experiential therapy, such as wilderness programs, which foster and depend upon the building of trust between peers. </li></ul><ul><li>Programs with positive peer culture can also be an important way to use the influences of attachments in a constructive way. </li></ul>
  54. 54. Challenges for working with young people ‘in care’. <ul><li>Many interventions designed to ‘protect’ children and adolescents e.g. removal from home and placement with a foster family or in a residential unit – may actually reinforce the young person’s view of the world as ‘unknown’, ‘uncontrollable’ and ‘frightening’. </li></ul><ul><li>These experiences can actually contribute to the traumatized child’s ‘catalogue’ of fearful situations. </li></ul>
  55. 55. Challenges for working with young people ‘in care’. <ul><li>Children in care need nurturance, stability, predictability, understanding and support. </li></ul><ul><li>They need frequent, repeated experiences of this in order to begin altering their view of the world from one that is uncaring or hostile to one that is caring and supportive. </li></ul><ul><li>Until that view begins to take hold in the child’s mind, they may not be able to truly engage in a positive relationship. </li></ul>
  56. 56. Intervention Issues <ul><li>The longer the child lived in an abusive or neglectful environment, the harder it will be to convince his/her brain that his/her world can change. </li></ul><ul><li>In order to ‘heal’ an ‘altered’ brain, interventions must activate the portions of the brain that have been altered. </li></ul><ul><li>Because brain functioning is altered by repeated experiences that strengthen and sensitize neuronal pathways, interventions must address the totality of the child’s life. </li></ul>
  57. 57. Thank you <ul><li>Any Questions? </li></ul><ul><li>I work at St Lukes on Mondays, Tuesday afternoons and Thursdays </li></ul><ul><li>I am located in the ICMS office </li></ul>