keeping attachment intact following trauma douglas goldsmith, ph.d. executive director the...
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Keeping Attachment Intact Following Trauma
Douglas Goldsmith, Ph.D.Executive Director
The Children’s Center18th Annual Conference on Child Abuse & Family Violence
October 2005
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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
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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?
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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 infant’s apparent perception of the availability of the caregiver if a need for comfort or protection should arise, and the organization of the infant’s 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 lonelyAttachment is mediated by looking, hearing, and holdingWhen I’m held I feel warm, safe, and comfortedResults in a relaxed state so that one can, again, begin to explore
•Holmes (1993)
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Secure Attachment
Attachment is a reciprocal relationshipThe 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 caregiver’s 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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Children’s Response to Trauma
Loss of sense of basic trustLoss of securityDestabilized “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 children’s distress
Withdraw to protect themselves emotionally
Difficulty tolerating children’s 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, somberAppleyard & Osofsky
(2003)
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Access to early memories
22 children 8-10 year oldsShown photos of preschool classmatesUnable to consciously identify the picturesBut pictures of children with whom they were familiar elicited reliable skin conductance responsesEarly 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 hospital5 months of age legal adoption is not completedSara enjoys a loving relationship with her parentsThe parent child relationship is marked by reliable, emotionally attuned, and responsive care
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The Case of Sara
Allegations of neglect ariseSara is removed from the home at the age of 10 months
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The Case of SaraShelter 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 procedureBelieving 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 environmentFirst adoptive family hasn’t 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?She’s so young that she won’t remember anything and can be returned without distressSara is a “resilient” child
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The Case of Sara
The internal working model – viewing the world through Sara’s eyesAssessing “risk”Could reunion reactivate feelings of loss?Utilization of second adoptive parents as a secure baseImpact of no contact
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Factors Favoring Sara’s 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 AgainstSara’s 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 Sara’s 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 assessmentsUnderstand children’s needs vs. parental capacity for caregivingDevelop 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
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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 child’s 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 haven’t 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