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Attachment And Children In Care 45 Slide Handout


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From the Conference for Children in Care and Children and Youth with Special Needs, May 2009

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Attachment And Children In Care 45 Slide Handout

  1. 1. Attachment and Children in Care Stephen Maunula, M.Sc., R. Psych. Assoc. Summit Psychology Group May 15, 2009
  2. 2. Attachment Theory <ul><li>Convergence of several fields of study - ethology (Konrad Lorenz ‘imprinting’) - interpersonal neurobiology - transactional model from developmental psycho-pathology or cognitive & interpersonal theories </li></ul><ul><li>Attachment refers to the bond of caring and craving that ties the child & caregiver to each other. A special emotional relationship is reflected in the infant’s preference for the caregiver when threatened or distressed, and the infant’s use of a caregiver as a secure base for exploration. </li></ul>
  3. 3. Attachment theory cont. <ul><li>Attachment system refers to the organization of a diverse set of behaviours in the infant that maintains proximity to the caregiver and ensures the survival of the infant and species. To activate the attachment system, the child must be under stress. </li></ul>
  4. 4. In plain language <ul><li>Bonding – “emotional glue” –bonded with love, i.e., to family, friends and loved ones. Bonding is the process of forming an attachment. </li></ul><ul><li>Some people are ‘naturally’ capable of loving; while others are ill-equipped to form intimate relationships. </li></ul><ul><li>Attachment capabilities – refers to the capacity to form and maintain an emotional relationship </li></ul><ul><li>Attachment – refers to the nature and quality of the actual relationship </li></ul>
  5. 5. Winnicott Problems in bonding during Infancy <ul><li>• Feeling of authentic experience emerges from spontaneously arising gestures, which the ‘good enough’ mother mirrors. </li></ul><ul><li>• If the baby's own impulses and needs are not met by mother, then the baby learns to become what the mother's idea of the baby is. </li></ul><ul><li>• In pathological attachment, the infant takes cues from outside him/herself. </li></ul><ul><li>• Deeply felt sense that &quot;something is wrong&quot; with the way I am: shut down of connection with direct feedback of the body. </li></ul><ul><li>• Capacity to feel inner realness becomes impaired. </li></ul>
  6. 6. Bowlby (1991) <ul><li>What cannot be communicated to the (m)other cannot be communicated to the self. </li></ul>
  7. 7. Secure vs. Insecure Attachments <ul><li>Secure attachment – child finds both safety/protection & support for exploration/autonomy from parent or caregiver within first few years of life </li></ul><ul><li>Insecure attachment a) Avoidant b) Ambivalent c) Disorganized (Disoriented) </li></ul>
  8. 8. Secure Attachment <ul><li>Secure attachment results from ‘attunement’ of parent with child’s needs </li></ul><ul><li>Concepts of ‘Good Enough’ parent, and ‘Goodness of Fit’ between child’s temperament and parenting capacity </li></ul><ul><li>Secure attachment results when a parent provides a safe haven to protect & comfort child, as well as a secure base from which the child can grow & learn </li></ul>
  9. 9. Secure Attachment results in: <ul><li>Good capacity for emotional regulation, including the ability to contain impulses when necessary, to express feelings when appropriate, and to become emotionally invested in activity. </li></ul><ul><li>A core sense of identity. </li></ul><ul><li>A fundamental confidence in others as caring and in the self as worthy. </li></ul><ul><li>An understanding of relationships which includes features of emotional openness, reciprocity, and responsiveness. </li></ul>
  10. 10. Insecure Attachment Patterns <ul><li>Avoidant – watchful, wary (hypervigilant), ‘slow-to-warm-up’; difficulty maintaining emotional closeness to others, difficulty directly expressing feelings, show limited engagement in emotionally arousing situations. </li></ul><ul><li>Ambivalent/Resistant – both clingy & angry, rejects contact, refuses to be comforted; heightened arousal and exaggerated emtional expression; easily frustrated, overstimulated, impulsive and overly anxious. </li></ul><ul><li>Disorganized/Disoriented – fearful and confused: infants may exhibit an array of seemingly undirected behaviour-al responses, i.e., ‘freezing’, hand-flapping, and stereo-typies; older children may take control of the parent by punitively controlling the parent or, alternately, caring for and comforting the parent. </li></ul>
  11. 11. Assessment of Attachment <ul><li>Ainsworth’s “Strange Situation Paradigm” </li></ul><ul><li>Classifications of Types A, B, C & D. </li></ul><ul><li>“ Circle of Security” Relationship Assessment </li></ul><ul><li>Adult/Adolescent Attachment Interview </li></ul><ul><li>DSM-IV diagnoses: - Reactive Attachment Disorder of Infancy or Early Childhood - Posttraumatic Stress Disorder </li></ul>
  12. 12. Strange Situation Paradigm <ul><li>The strange situation is a laboratory observation consisting of eight episodes in which the caregiver and a female stranger interact with, depart from, and reunite with, the infant (age 1 – 2 ½ years) in an environment which offers the child opportunities for exploration. </li></ul>
  13. 13. Strange situation and attachment patterns
  14. 14. What causes insecure attachment? <ul><li>Temperamental difficulties of child may cause strain in bonding between parent & child (ADHD, ASD, congenital defects, etc.) </li></ul><ul><li>Psychopathology of parent (depression, schizophrenia, own attachment disorder, etc.) </li></ul><ul><li>Alcohol/substance abuse by parent (FAS/E) </li></ul><ul><li>Childhood maltreatment through neglect, physical and sexual abuse </li></ul>
  15. 15. Factors contributing to psychopathology
  16. 16. Internal Working Models (IWM) <ul><li>Information, expectations, and feelings about other people (whether individuals will be responsive, trustworthy, accessible, & caring vs. unresponsive, untrustworthy, & uncaring) </li></ul><ul><li>Corresponding representations of themselves and their own role in these relationships (whether worthy & capable of obtaining others’ care vs. unworthy & uncapable) </li></ul><ul><li>IWM provides a ‘template’ for subsequent relationships with other people </li></ul>
  17. 17. The Internal Working Model <ul><li>• Defensive exclusion [of physical self experience- instituted to deal with alarm and fear of relational loss] becomes encapsulated in the individual's defensive structure: </li></ul><ul><li>• … . and are manifested in patterns of attachment (Bowlby, 1980). </li></ul>
  18. 18. Interpersonal Schemata (IS) <ul><li>Other interpersonal expectations derived from patterns of interaction with people other than the care-giver (e.g., teachers) </li></ul><ul><li>IS refer to general expectations of others’ probable responses to the self. </li></ul><ul><li>[Shirk, S.R. (1998) Interpersonal schemata in child psychotherapy: A cognitive-interpersonal perspective. Journal of Clinical Child Psychology , 27 , 4 – 16] </li></ul>
  19. 19. Can IWM/IS be changed through psychotherapy? <ul><li>“ Pessimistic model”: increasingly stable characteristics account for consistency in behaviour across time, self-fulfilling prophesy effects, and the failure of intervention in later life (relative to intervention in early life) Crick & Dodge, 1994 - Early intervention through Infant-Parent Psychotherapy - Compensatory interventions </li></ul>
  20. 20. Can IWM/IS be changed through psychotherapy? Cont. <ul><li>“ Optimistic model”: maintains that the maladaptive IS can be transformed. Potential change processes include the therapeutic relationship as a mechanism for change. New relationships introduce an element of discontinuity into the child’s life. </li></ul>
  21. 21. Interventions with Parents <ul><li>Infant-Parent Psychotherapy (IPP) [Frailberg, Adelson, & Shapiro, 1974] </li></ul><ul><li>Intervention directed at parental sensitivity – behavioural level [van den Boom, 1994] </li></ul><ul><li>Parent-Child Interaction Therapy (PCIT) [Hembree-Kigin & McNeil, 1995] </li></ul><ul><li>Interventions with foster parents and other caregivers on process & content issues </li></ul>
  22. 22. Interpersonal Neurobiology <ul><li>Principle 1. The brain is organized in an hierarchical fashion, that all incoming sensory input first enters the lower parts of the brain. </li></ul>
  23. 24. Neurodevelopmental Stages
  24. 25. Principle 2. Neurons and neural systems are designed to change in a ‘use-dependent’ fashion .
  25. 26. Neurodevelopmental principles cont. <ul><li>Principle 3. The brain develops in a sequential fashion. </li></ul><ul><li>Principle 4. The brain develops most rapidly early in life (90% of brain pathways occur before the age of 3 years). </li></ul><ul><li>Principle 5. Neural systems can be changed, but some systems are easier to change than others. </li></ul>
  26. 27. The primitive but social brain <ul><li>Principle 6. The human brain is designed for a different world (than the one we live in today). </li></ul><ul><li>In hunter-gatherer societies, adult:child ratio was 4:1. </li></ul><ul><li>In post-Modern society, adult:child ratio is ~1:4 @ home or 1:25-30 @ school. </li></ul><ul><li>If “it takes a village to raise a child”, then there is less adult community around kids these days to help them form lasting, secure attachments. </li></ul>
  27. 28. The role of Attachment & Security to Parent-Child Interactions <ul><li>The primary caregiver of a child plays many roles, especially during the pre-school years (e.g. playmate, teacher) </li></ul><ul><li>The role of the attachment figure (parent) is to PROTECT the child to ensure his/her survival </li></ul><ul><li>The attachment figure also helps in the development of SELF-REGULATION (i.e., of emotion, behaviour, thinking) in the child </li></ul>
  28. 29. Benefits of Secure Attachment <ul><li>Enjoy more happiness with their parents </li></ul><ul><li>Feel less anger at their parents </li></ul><ul><li>Get along better with friends </li></ul><ul><li>Have stronger (more secure) friendships </li></ul><ul><li>Are able to solve problems with others </li></ul><ul><li>Have better relations with siblings </li></ul><ul><li>Know that most problems have an answer </li></ul><ul><li>Trust that good things will come their way </li></ul><ul><li>Trust the people they love </li></ul><ul><li>Know how to be kind to those around them </li></ul>
  29. 30. Insecure or Disorganized Attachment: Outcomes <ul><li>Infancy – no coherent strategy for coping with stress </li></ul><ul><li>Toddlerhood – poor social skills, aggressive </li></ul><ul><li>Preschool & School Age – shift to controlling behaviour on part of child (e.g., punitive/defiant or parent-child role reversal) </li></ul><ul><li>Adolescence/Adulthood – Externalizing/ Internalizing difficulties; high rates of mental health problems </li></ul>
  30. 31. “ Circle of Security” for pre-schoolers
  31. 32. Need for consistency & continuity in care <ul><li>Stable and continuous foster home placements are necessary to allow sufficient time for child to overcome insecure attachment </li></ul><ul><li>What happens to children with insecure attachment who have multiple care-givers over time? (see diagram) </li></ul>
  32. 33. 2 routes to Permanent Detachment
  33. 34. Interpersonal difficulties <ul><li>Disrupted attachment style, difficulties with trust, low interpersonal effectiveness, sexual problems in adulthood, re-victimization, poor social skills and poor boundaries </li></ul><ul><li>Nearly 1000 studies document interpersonal difficulties after childhood interpersonal trauma (van der Kolk et al., DSM-V DTD Taskforce) </li></ul><ul><li>Maltreatment is associated with insecure attachment in children under 4 years old. </li></ul>
  34. 35. Process issues for insecurely attached children in care… a. <ul><li>Many children with attachment disorder also have: ADHD, ODD, Conduct disorder, Anxiety disorders, Speech & Language disorders, specific Learning Disability </li></ul><ul><li>Underlying attachment disorder needs to be recognized in placement & treatment planning </li></ul><ul><li>Continuity of Care is vitally important </li></ul>
  35. 36. Process issues continued…b. <ul><li>Early stage of containment when children are placed in care - ensure safety - ‘good-enough’ parenting - behaviour management (non-punitive) - certain intense ‘treatment’ may be counter-productive if the child is not ready – proper control of distance, i.e., be emotionally available but not intrusive – cannot force love/attachment on a child [Aesop’s fable of warm sun vs. forceful wind to ‘uncover’ the attachment-resistant child] </li></ul>
  36. 37. Process issues continued…c. <ul><li>Tentative attachment may begin - one adult may become special, and remain special even when child is demanding or frustrating (foster parent, teacher, etc.) </li></ul><ul><li>- at this point, child may become ‘accessible’ to treatment - long-term therapeutic foster care or staffed group homes need to have ready access to individual, group and family therapy </li></ul>
  37. 38. Parenting strategies <ul><li>Emotionally available but non-intrusive parenting </li></ul><ul><li>Be prudent re physical contact </li></ul><ul><li>Concrete demonstration of the caregiver’s caring and commitment </li></ul><ul><li>Include child in mutually enjoyable experiences </li></ul><ul><li>Firm limits re behaviour and verbalization of the reasons for limits; avoid control battles </li></ul><ul><li>Empathy and verbal articulation of feelings </li></ul>
  38. 39. Support for other caregivers (teachers, etc.) <ul><li>Educate about the functions of the child’s behaviour to minimize personalization (i.e., “The child is out to give me a hard time!”) </li></ul><ul><li>Support, encourage and teach parenting skills </li></ul><ul><li>Encourage caregivers to: take care of themselves; identify, acknowledge and cope with their reactions to children’s behaviour; identify and use supports; and find multiple sources of satisfaction in their lives. </li></ul>
  39. 40. Kootenay Kontext <ul><li>First Nations’ children in foster care </li></ul><ul><li>Fetal Alcohol Syndrome/Effects </li></ul><ul><li>Low high school graduation rate of children in care </li></ul>
  40. 41. Acknowledgements <ul><li>John Pearce, Ph.D., R.Psych. Child Abuse Service with Calgary Health Region </li></ul><ul><li>Attachment Disorders : Interventions with Parents and Caregivers, June 16, 1999 </li></ul><ul><li>Attachment Disorders : Intervention with Children, November 24, 1999 </li></ul><ul><li>Attachment Disorders : Diagnosis and Management, September 24, 2003 </li></ul><ul><li>Management of Attachment Disorders : School Age Children, March 24, 2004 </li></ul>
  41. 42. Acknowledgements cont...b. <ul><li>Paul D. Steinhauer, M.D., F.R.C.P.(C) Professor of Psychiatry, University of Toronto Staff Psychiatrist, Hospital for Sick Children </li></ul><ul><li>Attachment Disorder : A Neurodevelopmental Approach & Implications for Caregiving, Treatment & Case Planning </li></ul><ul><li>Workshop prepared for CRHA & Alberta Children’s Hospital, Child Abuse Program, Calgary, Alberta, October 23, 1998 </li></ul>
  42. 43. Acknowledgements cont…c. <ul><li>Karen Colburne, Ph.D. & Sonya Vellet, Ph.D. </li></ul><ul><li>Circle of Security Early Intervention Program for Parents and Children </li></ul><ul><li>Presentation to Child & Adolescent Psychology staff at Child Development Centre, Calgary Health Region fall 2008 </li></ul>
  43. 44. Acknowledgements cont…d. <ul><li>Bessel van der Kolk, M.D. </li></ul><ul><li>New Frontiers in Trauma </li></ul><ul><li>2 day workshop in Coquitlam, April 3 & 4, 2009 </li></ul><ul><li>Sessions on Trauma & Psychopathology, Attachment and Psychopathology, Childhood trauma and Psychiatric illness </li></ul><ul><li>Jack Hirose & Associates, Inc. </li></ul>
  44. 45. Acknowledgements cont…e. <ul><li>Bruce Perry, M.D., Ph.D. et al. </li></ul><ul><li>Bonding and Attachment in Maltreated Children: How abuse and neglect in childhood impact social and emotional development </li></ul><ul><li>V2.0 (1998) CIVITAS Initiative Press </li></ul><ul><li>See </li></ul>