Working with Young Children with Attachment Disorders and Their Families Tuesday 10 June 2014 12:30pm - 2:00pm AEST Before we start… • Ensure sound is on and volume turned up on your computer. • If you are experiencing problems with sound, dial in using your telephone as per details on your confirmation email (enter telephone number and password provided). • Dial 1800 733 416 for technical support (Redback). • Specific question/s may be asked throughout the webinar using the chat box - presenters will endeavour to answer them at the end of the webinar. PRESENTERS: Dr Dianne Camilleri Clinical psychologist Private practitioner Professor Louise Newman Infant psychiatrist Monash University Centre for Developmental Psychiatry & Psychology Facilitator: Harry Lovelock, APS Working with Young Children with Attachment Disorders and Their Families Copyright Dr Dianne Camilleri (June 2014) Outline of Presentation: A comment on the title of the presentation Attachment theory – overview and key concepts How does attachment theory help us understand our work with families? Aim of therapeutic work with infants/children with attachment problems Treatment with children experiencing attachment based difficulties Case example Copyright Dr Dianne Camilleri (June 2014) Introduction to the Title of the Presentation – Differentiating ‘disorder’ from ‘disturbance’ Title implies a more diagnostic category. HOWEVER, intention was to present more diverse attachment difficulties, rather than specific disorders. Formal attachment disorder is represented in diagnostic classification systems (such as DSM-V) as: (1) Reactive Attachment Disorder; (2) Disinhibited Social Engagement Disorder. Both disorders are seen as distinct/unique disorders. These disorders are not commonly diagnosed, and are diagnosed more in high risk populations (10-20% of the severely neglected group of children). • Zeanah (2010) suggests “… an attachment disorder is warranted when a child who is developmentally capable of forming attachments, does not because of an aberrant caregiving environment” (p. 31). • Todays’ presentation will focus on a broad range of attachment difficulties/disturbance, not just attachment disorders. Copyright Dr Dianne Camilleri (June 2014) Attachment Theory – Definition • Attachment as an evolutionary imperative. It represents: • “a child’s biological tie or bond to her primary caregivers, usually her parents. It is a biological system developed through evolution to protect the child, thus ensuring the likelihood she will grow into an adult and reproduce, thereby guaranteeing gene survival.” (Newton, 2008, p. 9). • Attachment works on the premise that we are ‘hard wired’ to seek out relationships with others that promote our physical and internal/psychological sense of security. • Attachment tells us about the child’s primary relationships and how it influences their development (eg social, emotional, cognitive). Copyright Dr Dianne Camilleri (June 2014) Attachment Theory – Characteristics • Attachment theory has its origins with John Bowlby. • Four key characteristics of attachment: • (1) proximity maintenance (wanting to be physically near to the persons we are closest to); • (2) safe haven (returning to attachment figure when feeling frightened or sense of threat (perceived or real)); • (3) secure base (the attachment figure represents a secure base from which the child can explore their environment and other relationships; • (4) separation distress (anxiety when attachment figure is absent). Copyright Dr Dianne Camilleri (June 2014) Attachment Theory – ‘Monotropic’ view • Bowlby’s concept of ‘monotropic’ attachment (ie preferred atttachment figure (usually the mother) above all others). • This view limited? Especially in current social and familial context – eg while mothers are still the primary caregiver for most children, infants/young children can have multiple ‘key’ caregivers (eg both parents being very involved in the care; grandparent providing part-time care while both parents work; childcare environments; etc). • Rutter (1995) also questions this monotropic view. Copyright Dr Dianne Camilleri (June 2014) Attachment Theory – Key Concepts • Attachment behaviour (observable) is activated in response to fear or separation from attachment figure and when infant/child perceives real or imagined threat exhausts their capacity to cope (Taylor, 2012). • Attachment continuum – child moves between proximity seeking and exploration. Copyright Dr Dianne Camilleri (June 2014) Attachment Theory – ‘Styles’ of Attachment • Attachment ‘styles’ – emerged from work of Mary Ainsworth and others following extensive observation and research of separation and reunion behaviours of infants ~1-2 years old. • Technique used to identify these styles was called ‘The Strange Situation’ (see attachment that follows for procedures from Prior & Glaser, 2006, p. 100). Copyright Dr Dianne Camilleri (June 2014) Copyright Dr Dianne Camilleri (June 2014) Attachment Theory – ‘Styles’ of Attachment (cont.) • Attachment styles identified by Mary Ainsworth: • Secure (62-66% of children) • Insecure • Anxious-avoidant (15-22% of children) • Anxious-ambivalent (9-12% of children) • Disorganised (category identified by other researchers, 15% of children) – Louise to focus more on this one (See following slide for descriptions of secure, avoidant and ambivalent attachment styles – excerpt from Karen, 1994, p. 444-445) Copyright Dr Dianne Camilleri (June 2014) Copyright Dr Dianne Camilleri (June 2014) Attachment Theory – Secure Attachment • Secure attachment: • develops from a relationship with primary caregiver(s) which provides a range of important characteristics/features such as sensitivity and responsiveness, including attunement, availability, understanding, warmth, and consistency (at least most of the time); • provides an opportunity for the child to gradually and increasingly explore their world beyond the primary relationship(s) to other relationships and experiences, knowing they can return when needed (during moments of feeling fearful/insecure again). • Secure attachment experience is eventually internalised (or taken into their minds as a mental representation), allowing child to draw on this internal sense of felt security without the actual presence of the caregiver. Refer to this as ‘internal working models’. Copyright Dr Dianne Camilleri (June 2014) From: http://confustulation.com Copyright Dr Dianne Camilleri (June 2014) Attachment Theory – Attachment styles (cont.) • Secure, anxious-avoidant and anxious-ambivalent attachment are all considered ‘organised’ forms of attachment – ie there is consistency in the infant/child’s attachment behaviour under stress. • Disorganised attachment, as the name suggests, describes children that lack an organising framework for their attachment experiences and lack a consistent response in their attachment behaviour (eg can exhibit a range of confused responses, include secure, avoidant, ambivalent). Copyright Dr Dianne Camilleri (June 2014) Attachment Theory – Attachment styles (cont.) • For a brief video clip of a child with ‘secure’ attachment, view: http://www.youtube.com/watch?v=QTsewNrHUHU While viewing this clip, refer back to descriptive table for ‘secure’ attachment behaviours in infants. Copyright Dr Dianne Camilleri (June 2014) Attachment Theory – Stability of Attachment Styles Over Time • Once developed, attachment styles remain relatively stable across time (without changes in caregiving environment that is). • The younger the infant, the more malleable the attachment style. Copyright Dr Dianne Camilleri (June 2014) Attachment Theory – Association Between Parenting Styles and Different Attachment Styles • Parenting styles associated with anxious-avoidant attachment (Newton, 2008): • limited care of infant’s needs; • frequent rejection of infant’s need for proximity and sensitive care; • tendency to encourage greater autonomy than is health or developmentally appropriate for the child. • These children often present with a false sense of independence and tend not to seek parents out for comfort or safety. Copyright Dr Dianne Camilleri (June 2014) Attachment Theory – Association Between Parenting Styles and Different Attachment Styles • Parenting styles associated with anxious-ambivalent attachment (Newton, 2008): • inconsistent care; • heightened focus and response to fearfulness in infant which exacerbates the infant’s fear; • discourages exploration (due to parental anxiety). • These children often give mixed messages to the parent – simultaneously hostile and dependent toward parent. • They are hypervigilant to possibility of separation from attachment figure, and seek to be proximally close even at times seemingly not necessary (eg clingy behaviour) due to uncertainty about the parents’ ongoing availability. Copyright Dr Dianne Camilleri (June 2014) Attachment Theory – Limitations of Categories • While categories are important, need to keep in mind that infants/children can exhibit different styles under different circumstances or with different caregiver(s). • What is more relevant to attachment ‘style’, is knowing from your assessment (and formulation) how their attachment style manifests, or plays out, in the child’s relationships with others. Copyright Dr Dianne Camilleri (June 2014) Attachment and Post-Natal Depression in Mothers • Impact of PND on infants’ attachment – depending on level of ‘buffering’ by others (eg partner, extended family, other supports), infant attachment may be quite compromised. • Research suggests that while mothers who receive treatment for their PND get better (ie symptoms resolve), any negative impact on the infant’s attachment is not automatically corrected as a result. • Mothers often feel tremendous guilt during episodes of PND and later in relation to their lack of emotional availability (or even physical neglect) during their episode of PND. Copyright Dr Dianne Camilleri (June 2014) Attachment Theory – Whose Attachment? • When we talk about attachment in relation to infants/children, we are referring to the infant’s attachment to their primary caregiver(s), not the other way around! Copyright Dr Dianne Camilleri (June 2014) How Does Attachment Theory Help Us Understand Our Practice/Treatment Provides a framework for understanding a child’s relationships with attachment figures, and how these relationships influence other relationships in their lives, and their behaviour, self-concept, etc. Helps us understand the child’s relationship with us as the therapist, and others in their life who aren’t in their immediate caregiving system (eg teachers or peers at school; their dance teacher; meeting new people). However, attachment is only part of an Ax with an infant/child, it’s part of my understanding of a child’s difficulties. Copyright Dr Dianne Camilleri (June 2014) Assessing Attachment See notes attached. Attachment to presentation by Dr Dianne Camilleri on ‘Working with Children with Attachment Disturbance and their Families’ on 10 June 2014 ATTACHMENT 1 – ASSESSING ATTACHMENT: Trying to develop an understanding of both the infant/child’s and the parent’s attachment (both the observable behaviour and mental representations of attachment) will be important. Some aspects of your Ax may include: Infant’s/Child’s attachment: · observation of how the child manages separation from parent(s) during individual assessment (use with children ~4 years and older); how do they respond to the separation? Eg crying, clinging, refusing to go with you to, go with you but do not explore the consulting room and toys once inside, frequently ask when they can go out to their parent or wanting reassurance that their parent is in the waiting room, etc; · observations during family or parent-infant/child interview – how is infant/child relating to parent; does child seek comfort at any stage; if so, how does parent respond; how in tune with the infant/child is the parent [eg the infant signals she is tired, but the parent interprets this as the infant wanting to be put down on the mat to play with the toys]; · observation of infant/child and parent(s) playing together (instructions may be something like: “I’d like the two/three of you to just play freely as you might at home together, and I’m going to sit back and not be involved. Try and forget I’m here (I know that’s difficult). We’ll do this for about 10-15 minutes.” Purpose of doing this is that it is (a) unstructured; (b) produces a little bit of anxiety which will make the attachment style more overt; (c) see how the child initiates comfort from parent, proximity seeking, is there reciprocal interaction, evidence of symbolic play; for older children, how does conflict get managed (eg does it emerge and how is it responded to/dealt with/managed – also looking for how the parent is managing this; eg does the parent try to shut things down, do they respond with anger, do they freeze, do they criticise, do they follow the child’s lead or do they lead the play, etc; · what does the child say (if old enough) about his/her relationship with parent(s)/others? · pay attention to transitions – often children with attachment difficulties find transitions difficult – could be transitions to bedtime, to school, to childcare, etc, as reported by parents and child. Parents’ own attachment history: · Parents’ own history is important as it will provide information as to their attachment experience in their family of origin. Important as there is a strong correlation between parent’s attachment style and their infant/child’s attachment style. Eg insecure-dismissing parents tend to be associated with more avoidant style in child and they tend to overly encourage autonomous behaviour; insecure-preoccupied parents tend to be associated with insecure-avoidant style in child and feel anxious about their child’s exploratory behaviour and so discourage it (Prior, V., & Glaser, D., 2006, p. 51). 1 Copyright Dr Dianne Camilleri (June 2014) What Are Some Possible ‘Red Flags’ That May Suggest Attachment Based Difficulties? • In infants, some ‘red flags’ may be: • • • • • • • • • • persistent settling, sleep or other regulatory problems; persistent crying; gaze avoidance; frequent/persistent irritability; feeding difficulties; tantrums, biting, aggression, etc; bonding difficulties; loss of significant attachment figures; infants with chronic ill-health; history of trauma. Copyright Dr Dianne Camilleri (June 2014) What Are Some Possible ‘Red Flags’ That May Suggest Attachment Based Difficulties? (cont.) • In pre-school or primary school aged children, some ‘red flags’ may be: • separation difficulties; • no clear preference for their primary caregivers; • relational problems with peers that is unexplained by a pervasive developmental delay or ASD problem; • excessive and intense ‘temper tantrums’; • regressions in milestones; • difficulties in developmentally appropriate exploratory behaviour; • excessive shyness, sensitivity and/or fearfulness; • loss of significant attachment figures; • history of trauma. Copyright Dr Dianne Camilleri (June 2014) Aims of Therapeutic Work with Children with Attachment Based Difficulties • The aim of therapeutic work with families is to: • increase the security of the infant’s/child’s attachment relationships with their primary caregivers, and thereby with others; • increase parents’ reflective functioning [see comments to follow, but essentially thinking about thinking/feelings rather than reacting/judging]; • alleviate the presenting difficulties that the child is exhibiting that you believe have insecure attachment at their core; • helping the parent connect with their child in a more authentic way, without their past history contaminating their relationship with their infant/child, and being able to be more responsive to the child’s needs; • helping caregivers and their children create opportunities for repair in their relationship (ie responding/interacting/thinking differently). Copyright Dr Dianne Camilleri (June 2014) Treatment – Importance of a Good Formulation • Good beginning to treatment is having a good formulation (which follows on from your assessment). • See attached notes regarding important aspects of the formulation. Attachment to presentation by Dr Dianne Camilleri on ‘Working with Children with Attachment Disturbance and their Families’ on 10 June 2014 ATTACHMENT 2 – FORMULATION AS A GOOD BEGINNING TO TREATMENT: · Attachment theory is usually only part of the story - it won't always explain everything, & this is where a initial period of Ax and good formulation and understanding of child development is important. · The basis of any therapeutic work is a good formulation. A good formulation should be based on your assessment of the child’s difficulties. This will include the questions of ‘What factors may have influenced the infant’s/child’s presenting problems’, ‘What is continuing to maintain the infant’s/child’s presenting problem(s)?’, ‘What strengths are there in this infant/child/caregiver(s)/systems supporting the child/family?’. Sharing key aspects of your formulation with parents will form the basis of your treatment and is a crucial beginning to any treatment, because: o it lets the family know you have been listening and that they have not given all the assessment information in vein; o shows the family you understand the child’s difficulties and their struggle as a family; o provides an opportunity for a shared understanding of the child’s difficulties – if not, the therapy is unlikely to flow on positively from your Ax; o provides an explanation that you will continue to reflect on and use in the therapeutic work (eg reiterating patterns that are unhelpful in the child-caregiver relationship); o acknowledges that all behaviour has meaning – aim to understand the meaning underlying an infant/child’s behaviour, or overt presentation, rather than the behaviour being an isolated and random occurrence that can be treated in isolation of their relationships with others; o it begins the psycho-education process embedded within the work. Copyright Dr Dianne Camilleri (June 2014) Treatment – Important Definitions Some important definitions: • Reflective functioning – Slade (2008, p. 214) describes reflective functioning as: “Reflective functioning can be understood narrowly as the capacity to understand one’s own and others’ behaviour in terms of underlying mental states and intentions, and more broadly as a crucial human capacity that is intrinsic to affect regulation and productive social relationships.”. • This capacity is narrowed or limited in some parents, and consequently underdeveloped in their children who develop insecure attachments. It is about the capacity to reflect rather than react or judge the child, and to make sense of and be open and curious to internal states and experiences of oneself and one’s child. • Eg your child throws your favourite ornament on the floor out of anger and it cracks. Rather than react (punish, express anger toward the child, tell the child their behaviour was bad, etc), you think about what may have lead your child to act this way, why that ornament, what do you think he was trying to achieve, do you think he understood the significance of the ornament, and so on. Copyright Dr Dianne Camilleri (June 2014) Treatment – Important Definitions (cont.) • Some important definitions (cont.): Ghosts in the nursery: central idea to working with parents. It refers to the negative influences on current relationships (ie with one’s infant/child) from past relationships/history. Fraiberg, Adelson, & Shapiro (1975) state: “In every nursery there are ghosts. They are the visitors from the unremembered past of the parents, the uninvited guests at the christening. Under all favorable circumstances the unfriendly and unbidden spirits are banished from the nursery and return to their subterranean dwelling place. The baby makes his own imperative claim upon parental love and, in strict analogy with the fairy tales, the bonds of love protect the child and his parents against the intruders, the malevolent ghosts.” However, in some circumstances, “… The intruders from the past have taken up residence in the nursery, claiming tradition and rights of ownership. They have been present at the christening for two or more generations. While no one has issued an invitation, the ghosts take up residence and conduct the rehearsal of the family tragedy from a tattered script.” (p. 388). Copyright Dr Dianne Camilleri (June 2014) TREATMENT – HOW DO WE HELP A CHILD AND CAREGIVER(S) REPAIR THEIR RELATIONSHIP? • Empathise with how difficult it may be for both parents & infant/child. • Encourage/promote consistent, sensitive, responsive, attuned, caregiving and replicate this in the therapeutic relationship. • The therapeutic relationship needs to mimic secure attachment characteristics – eg therapist provides consistency (environment and time), reliability, attunement (to both parent(s) and infant/child), reflective capacity, containment by therapist (ie ability of the therapist to tolerate the intolerable feelings/thoughts/etc of the parent(s) and/or child. • Explore what is getting in the way of parent providing this (go back to your formulation and observations for this). • Help families to create new ways of relating through play, and exploratory discussion in order to increase their capacity to reflect and to offer what their infant/child needs. Copyright Dr Dianne Camilleri (June 2014) Treatment – Some Guiding Principles • Tools you may use to create reparative conversations with the parent(s) and child: photos (may be recent, may be when child was an infant) or special objects (eg a baby blanket that has special meaning; baby’s first tooth; etc – bring into the room something very real about the family; • Attempting to use in vivo moments in the sessions to explore the parent-infant/child relationship (eg the child seeks comfort; there is conflict in the session; the parent doesn’t know how to play with their infant/child; etc). • Use of play with infants/children and parent(s) as a way of engagement and therapeutic change. Copyright Dr Dianne Camilleri (June 2014) Treatment – Some Guiding Principles (cont.) • Some parents have a lot of trouble just ‘being with’ their child or playing with or enjoying their infant/child. This may be due to their anxiety that they have nothing to offer, that they have too many competing demands, that they dislike their child, etc. However, if the relationship between child and parent(s) is to improve, developing a sense of comfort in being in each other’s company (without judgement/criticism, etc) is crucial; the therapist here is a facilitator/bridge between the infant/child and their parent(s). • Observations of the parent-child interactions or the play. • One approach that uses a reflective stance in parent-infant work can be found in an approach developed by Muir, 1992 called ‘Watch, Wait & Wonder’. (See reference). Copyright Dr Dianne Camilleri (June 2014) Who is Involved in Treatment? • Who is involved in sessions? • Parent only – child-focussed (although with infants, almost always see parent-infant together – some exceptions). • Parent and infant/child joint sessions. • Alternating between parent-child and child-focussed parent sessions. • Important that parents are always involved in treatment, especially given attachment disturbance occurs in a relational context (see Slade, 2004 and Hopkins, 1991). Copyright Dr Dianne Camilleri (June 2014) Treatment – Parent-Infant/Child Joint Sessions • What might a parent-infant/child session look like?: • Brief ‘catch up’ period at the beginning of session. Keep ‘ear open’ for differences reported (eg “We had a good night last night. He slept through and I felt well rested this morning. This hasn’t happened for months”). • Invite parent to play with their infant/child (may need to model this to parent (eg get down on the ground first; say “come and join us down here” [unless infant newborn]). • Once play has got going, watch, wait and then may wonder out loud with parent or make observations about play – eg parent and child at dolls house: “I notice there is a lot of fighting in this [play] family”; may ask parent “I wonder what you think is going on in this play at the moment?”. Copyright Dr Dianne Camilleri (June 2014) Treatment – Parent-Infant/Child Joint Sessions (cont.) • We are assisting parent(s) to develop greater reflective capacity. Eg. child may throw a toy at the parent and, say, parent withdraws from child. Could use this as an entry point for exploration – what is the parents’ experience of this interaction? What does parent think is child’s motive? What do they think this was about for their infant/child (eg defiant? sadistic? lack of self-control? etc). • May offer observation: eg “I wonder if you withdraw from Sam when he throws something at you as maybe having something to do with your earlier comments that you believe you are a hopeless parent?”. • There may be room to guide/coach the parent to respond differently (eg “What do you think would happen if you took the toy & returned it to Sam and said “I’m not sure what just happened between us?” and ask parent to think about how Sam might respond. Copyright Dr Dianne Camilleri (June 2014) Treatment – Child-focussed Parent Work • Child-focussed parent work (not the same as individual therapy for the parent): • attempting to help parents enhance their reflective functioning capacity; • explore parent’s history, their negative feelings toward their child (eg “when I look at him I see is a monster”), or their lack of self-confidence as a parent (eg “I have nothing to offer my child”); • help parents to disentangle negative aspects of their own histories from intruding into relationship with their infant/child; • psycho-education about infant/child emotional functioning; Copyright Dr Dianne Camilleri (June 2014) Treatment – Child-focussed Parent Work (cont.) • explore the parents’ projections (eg asking parents to think about where their perceptions, feelings, thoughts, etc, about the child belong); • explore their perceptions and interpretations about their infant/child’s behaviour (parents will make their own interpretations about the meaning of their child’s behaviour – eg: “he’s just wilful – he just doesn’t want to go to bed”; “she is manipulative – she will just constantly want my attention”; “she is fiercely independent – she never wants me to comfort her, even when she hurts herself badly”; etc0; • Example: 7-year-old boy who has always reminded his mother of her violent exhusband (boy’s father) – gently helping her to understand that this does not belong to her son and his and her relationship – eg “In what way is Eli different to your exhusband?” or “How is Eli’s anger different to your ex-husband’s anger”; etc). Could perhaps point out differences you have observed/heard as part of the therapeutic conversations and checking out your observations with the parent (eg “I’ve noticed that when Eli gets angry with you, once he has calmed down he doesn’t ‘hold a grudge’ like you say your ex-husband used to after he was abusive. What do you think?”). Copyright Dr Dianne Camilleri (June 2014) Treatment – Child-focussed parent work (cont.) Slade (2008) describes some ways of working with parents to enhance parental reflective functioning: creating a context for meaning making, or a thinking space; we hold the parent in our mind (as the therapist); we hold the infant/child in mind until the parent can hold their infant/child in mind (don’t expect the parents’ capacity to be very high at the beginning of treatment); we model a reflective stance (eg if a parent is overtly verbally attacking us (“You don’t have an f……. clue”), that we don’t respond with reactivity or defensiveness, but instead wonder with the parent about the experience of feeling helpless, or angry, or disappointed by me, or whatever); working at a level the parent can manage (going at the parents’ pace); being flexible in the way you work. Copyright Dr Dianne Camilleri (June 2014) Case Example – ‘Chloe’ Chloe – 3.5 years. Referred due to: • frequent and intense tantrums (++daily), would become highly distressed, demanding, scream; despite seeking comfort, she was often unable to use comfort offered by parents [characteristic of ambivalent attached children] • described as being unhappy, often irritable or overtly angry and upset easily; • family (particularly her mother) often gave into Chloe at times because they could not tolerate her distress and to avoid escalation in her behaviour; • extreme distress upon separation at childcare, where she had attended one day per week for the previous two years; in the first year, she would cry on and off the entire day; she made no emotional connection with any of the caregivers in the two years she had been attending; their strategy to manage her extreme separation anxiety was to ignore her, as they believed to try to comfort her made it worse. In more recent times, she continued to exhibit separation distress, but would settle within 10 minutes or so; • Chloe was reported to be highly anxious even in very familiar social situations [overly-anxious, compromised exploratory behaviour] (such as regular attendance at her sister’s dance group with mother present where she would stay constantly next to her mother throughout; Copyright Dr Dianne Camilleri (June 2014) Case Example – ‘Chloe’ (cont.) • she had some tactile sensitivities – frequent ‘fighting’ against her parents when they needed to strap her into the car, the pram or bath her or wash/brush her hair; • difficulties going to sleep at night without one of her parents laying with her until she fell asleep; [separation distress]; • both parents were overwhelmed by Chloe’s challenging behaviour, but particularly Chloe’s mother who was her primary caregiver; • Chloe was often angry toward her parents, and they found it difficult to offer her comfort and support because of her mixed messages of wanting them to support her, but being unable to be soothed [ambivalent attachment style] • Mrs [X] talked about having moments of complete despair and had thoughts of wanting to harm her daughter; underlying rage toward her; • developmental history: unsettled as an infant; mother had expected to be very competent in her parenting given this was her third child, but was intensely disappointed when Chloe experienced sleep, settling and feeding difficulties [‘red flags’ for potential attachment difficulties] Copyright Dr Dianne Camilleri (June 2014) Case Example – ‘Chloe’ (cont.) • mother would respond to Chloe’s need to be close to her inconsistently – sometimes providing comfort and sensitivity, other times rejecting Chloe and expressing angry feelings toward her; at bedtime, Mr [X] had to support Chloe to get to sleep because Mrs [X] became too frustrated with her [inconsistent parenting style of responding to proximity seeking behaviour in child] • History: mother had PND; Chloe conceived during period of significant stress for mother in context of death of her mother during pregnancy (complicated relationship with her); Mrs [X] felt belittled within her family [which had left her sense of self as incompetent and she applied this to her belief about herself as a parent]; extreme feelings of inadequacy as a mother which were compounded by her depression; [++’ghosts in the nursery’] • Father had history of significant Hx of depressive and anxiety problems (which would manifest at times with explosive anger outbursts); difficult relationship with his own parents who were supportive but father passive and didn’t manage conflict or emotions well; [ghosts in the nursery] Copyright Dr Dianne Camilleri (June 2014) Case Example – ‘Chloe’ (cont.) • individual assessment – Chloe found it very difficult to leave her mother in reception; we decided to do a graduated transition to Chloe’s mother waiting just outside the consulting room. Chloe was able to explore the consulting room and toys some of the time; however, when I approached her with a question, invitation to play with something, etc, she withdrew from me and became more inhibited in her play; • treatment included alternating sessions between (1) Chloe and her mother, (2) mother alone and (3) mother and father alone; • dyad work: Chloe would become angry with the initial ‘catch up’ phase, as she didn’t like to have to ‘share’ her mother with me, so after a few sessions of doing this, we decided to move directly into play when entering the consulting room. Chloe had intense difficulty with the transitions [often emerges with attachment difficulties] in and out of the sessions (not acknowledging me at the start, but not wanting to finish and leave at the end). The dyad sessions offered both Chloe and her mother an opportunity to re-learn how to enjoy each other (something her mother had never really felt with Chloe); Copyright Dr Dianne Camilleri (June 2014) Case Example – ‘Chloe’ (cont.) • dyad sessions were used to explore relationship, allow opportunities for Chloe to seek closeness to her mother without rejection, thinking about Chloe’s play and interactions with her mother and me; • parent therapy: • sessions with mother alone were focussed on her feelings of inadequacy, her feelings of intense rage toward Chloe, her relationship with various family members, her history, her complicated relationship with her deceased father; • sessions with both parents – focus was on finding alternative ways of seeing Chloe’s behaviour (eg rather than her behaviour as oppositional or uncooperative, seeing it as frightened) and thinking about how they were responding to Chloe during times of distress/anger/challenging behaviour/etc. • other aspects to the treatment: managing the transition to kindergarten – gradually reducing maternal support, photos of the teacher (with permission) and the kindergarten environment, visits to the kindergarten, using names of kindergarten teacher & peers prior to starting. [providing support using your formulation of her difficulties to guide her transition to kinder] Copyright Dr Dianne Camilleri (June 2014) http://www.condenaststore.com/-sp/I-keep-forming-inappropriate-attachments-New-YorkerCartoon-Prints_i8751358_.htm Copyright Dr Dianne Camilleri (June 2014) References for Further Exploration! • The following are some references that are not all attachment specific, but provide good guidance for child-focussed parent therapy generally, and share many of the same principles of attachment based thinking: Daniel Hughes uses attachment concepts extensively in his work. In his book ‘Brain-Based Parenting’ (2012), he advocates a model he calls PACE (playfulness, acceptance, curiosity and empathy). He suggests paying attention to these areas applies equally to the parent-child relationship and to the therapist-parent relationship (to promote trust and connection). Slade, A. (2008). Mentalization as a frame for working with parents in child psychotherapy (pp. 307-331). In E. Jurist, A. Slade, & S. Bergner (Eds.). Mind to Mind: Infant Research, Neuroscience and Psychoanalysis. NY: Other Press. Rustin, M. (1998). Dialogues with parents. In Journal of Child Psychotherapy, 24(2), 233-252. Slade, A. (2008). Working with parents in child psychotherapy. Engaging the reflective function. (pp. 207-234). In Mentalization: Theoretical Considerations, Research Findings, and Clinical Implications. F. N. Busch (Ed.). NY: The Analytic Press. Hughes, D. (2012). Brain-Based Parenting: The Neuroscience of caregiving for Healthy Attachment. NY: W.W. Norton & Company. [Some helpful ideas regarding managing emotion regulation in the therapy room – pp. 163-183.] Copyright Dr Dianne Camilleri (June 2014) References for Further Exploration! Family therapy approaches to working with attachment based difficulties: ‘Attachment-Focused Family Therapy’ (book) – Daniel A. Hughes (primarily used with families where child is in foster care, multiply placed child, adoption). ‘Rewriting Family Scripts’ (book) – John Byng-Hall. These approaches take a whole family approach to treatment, recognising that unhelpful attachment patterns within a family may be the protagonist for a child’s presenting problems and underlying attachment difficulties. Copyright Dr Dianne Camilleri (June 2014) References (used throughout presentation) Berlin, N. (2008). Tripartite therapy with older children: mutuality in the relationship of a parentchild attachment. In Journal of Child Psychotherapy, 34(3), 335-363. Bleiberg, E. (2002). Attachment, trauma, and self-reflection: Implications for later psychopathology. In J. M. Maldonado-Durán (2002). Infant and Toddler Mental Health: Models of Clinical Intervention with Infants and Their Families, (pp. 33-56). Cassidy, J., & Shaver, P.R. (Eds) (2008). Handbook of Attachment. Theory, Research, and Clinical Applications (2nd ed.). NY: The Guilford Press. Fraiberg, P., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to the problem of impaired infant-mother relationships. In Journal of the American Academy of Child Psychiatry, 14: 387-422. Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant-mother relationships. In Journal of the American Academy of Child Psychiatry, 14(3): 387-421. George, C., Kaplan, N., & Main, M. (1996). Adult Attachment Interview protocol (3rd ed.). Unpublished manuscript, University of California at Berkeley. Hopkins, J. (1991). Failure of the holding relationship: some effects of physical rejection on the child’s attachment and inner experience. In C. M. Parkes, J. Stevenson-Hinde, & P. Marris (1991). Attachment Across the Life Cycle. London: Routledge, (pp. 187-198). Karen, R. (1994). Becoming Attached: First Relationships & How They Shape Our Capacity to Love. NY: Oxford University Press. Copyright Dr Dianne Camilleri (June 2014) References (used throughout presentation) (cont.) Lieberman, A. (2002). Treatment of attachment disorders in infant-parent psychotherapy. In J. M. Maldonado-Durán (2002). Infant and Toddler Mental Health: Models of Clinical Intervention with Infants and Their Families, (pp.105-128). Muir, E. (1992). Watching, waiting, and wondering: Applying psychoanalytic principals to motherinfant intervention. In Infant Mental Health Journal, 13(4), 319-328. Newton, R. (2008). The Attachment Connection: Parenting a Secure & Confident Child Using the Science of Attachment Theory. Oakland, CA; USA: New Harbinger Publications, Inc. Newton, R. (2008). The Attachment Connection: Parenting a Secure & Confident Child Using the Science of Attachment Theory. Oakland, CA: New Harbinger Publications, Inc. Prior, V., & Glaser, D. (2006). Understanding Attachment and Attachment Disorders: Theory, Evidence and Practice. London: Jessica Kingsley Publishers. Rutter, M. (1995). Clinical implications of attachment concepts: retrospect and prospect. In Journal of Child Psychology and Psychiatry, 36(4): 549-571. Slade, A. (1999). Representation, symbolization, and affect regulation in the concomitant treatment of a mother and child: Attachment theory and child psychotherapy. In Psychoanalytic Inquiry, 19(5): 797-830. Slade, A. (2004). The move from categories to process: Attachment phenomena and clinical evaluation. In Infant Mental Health Journal, 25(4): 269-283. Taylor, C. (2012). Empathic Care for Children with Disorganized Attachments: A Model for Mentalizing, Attachment and Trauma-Informed Care. London: Jessica Kingsley Publishers. Zeanah, C. (2010). Reactive Attachment Disorder: A Review for DSM-V. American Psychiatric Association. Copyright Dr Dianne Camilleri (June 2014) ATTACHMENT THEORY disorganisation and development Professor Louise Newman AM Centre for Developmental Psychiatry and Psychology Monash University DEVELOPMENT IN INFANCY • • • • • • Neuropsychological processes Affect regulation Representations of self, other Attachment Style Adaptation to Stress Capacity for intimacy and empathy INFANT COMPETENCE • • • • • Perception of affective signals Communication of internal states Complex social responses Environmental interaction and processing “A pre-wired knowledge of the world” Stern TRAUMATISED AND TRAUMATISING PARENTS • Parents with unresolved traumatic attachment issues and histories of maltreatment/neglect • Range of issues and conflicts when they attempt to parent – from anxiety to avoidance to repetition • Opportunity for the prevention of disturbed parenting and abuse HIGH RISK PARENTING • Parenting relationships which impact adversely on child development and particularly on security of attachment • Spectrum of parenting behaviors, emotional responses, attitudes and conflicts (conscious and unconscious) which are traumatizing for the child and result in disorganization of attachment and impact on emotional and behavioral regulation • Influenced by parental attachment history, reflective capacity and mental state TRANSGENERATIONAL TRAUMA • Patterns of traumatising parenting are often repetitions • Maltreatment, abuse and exposure to violence in infancy are risk factors for later abusive behaviour and revictimisation • Prevention of child maltreatment involves identification of high-risk parents and early intervention THE LEGACY OF TRAUMA • Trauma is reenacted in the relationship with the infant • Unresolved parental attachment trauma is reflected in the handling and care of the infant • Trauma disrupts emotional interaction and regulation BIOLOGICAL FUNCTION OF ATTACHMENT BEHAVIOUR • Human infants have an innate capacity to form attachment relationships • Attachment has species-survival value • Attachment behaviour is organised as a goalcorrected system • Attachment behaviour is present from birth ATTACHMENT AND DEVELOPMENT • Secure attachment is based on empathic, responsive and consistent emotional care • Security of attachment promotes neurobiological and psychosocial development and resilience • Early caretaking experiences and the emotional environment are the foundations of psychological health CRITICAL PERIODS • The first two years are critical periods for the development of emotional understanding and attachment relationships • Trauma and disruption in this period will have implications for personality development and mental health • Attachment disorganisation represents a failure to develop an effective strategy to deal with anxiety about the carer – persistent unresolvable stress; the “paradox of maltreatment”; • Impact on models of self and relationships - trust, thinking and reflection, self representation BOWLBY’S ATTACHMENT THEORY • Intrinsic essential capacity for attachment • Internal representations of self, other and relationships • Influence of separation, loss and disruption insecurity, self-concept, repetition of dysfunctional patterns ATTACHMENT BEHAVIOUR • (1) Concerns a class of behaviour separate to feeding and sexual behaviour. • (2) Concerns relationships, rather than 'drives' or 'energies' (Freudian model). • (3) Differs from dependence. • (4) Co-exists with exploratory behaviour. TRAUMATISED PARENT • Unprocessed traumatic memories • Infant as a projective focus – misinterpretation • Infant experienced as anxiety provoking, persecutory, hostile Patterns in high risk families Distorted representation of the child Parental preoccupation with past trauma Parental anxiety Parental deficit in interpretation of the infant emotional communication • Problems in interpersonal functioning\ • Limited reflective capacity • • • • PARENTAL REFLECTIVE FUNCTIONING • Capacity to understand own and child's behaviour in terms of underlying mental states • Basis of parents ability to hold the infants affective experience in mind • Gives meaning to the child’s affective experience and re-presents it to the child in a regulated fashion PARENTAL REFLECTIVE FUNCTIONING • RF is the basis of parental access to their own emotions and memories of their own early attachment experiences • Mediates the reworking of parents early relationships in the transition to parenthood and representation of the child • Impacts on interactive and parenting behaviours THINKING ABOUT THE BABY • Crucial in establishment of attachment relationship and emotionally attuned early interaction • Gives infant experience of being validated and contained and is the beginning of self development INTERNAL WORKING MODELS • Mental representation of the self, the other and their relations • Formed from generalised representations of events • Include feelings, beliefs, expectations, behavioural strategies and rules for directing attention, interpreting information on and organizing memory • Models affect future relationships and patterns MULTIPLE MODELS • Child may develop two conflicting internal models of an important relationship • Traumatic models and experiences may be unconscious but still influence relationships, feelings and interactions PARENTING BEHAVIOUR AND ATTACHMENT • Mothers’ attributions, beliefs and feelings about the infant reflect her own attachment history • Secure mother has capacity for sensitive responsiveness and containment • Maternal state of mind regarding attachment influences the emotional, non-verbal interaction with the infant AINSWORTH AND ATTACHMENT THEORY • Strange Situation Procedure - secure and insecure patterns • Parental responsiveness to infant affect and secure attachment • Longitudinal studies of attachment patterns • Secure attachment promotes competence emotional, relationship, narrative, learning. ATTACHMENT PATTERNS • • • • Avoidant Secure Ambivalent Disorganised • • • • Dismissing Autonomous Preoccupied Unresolved ATTACHMENT DISORGANISATION • Associated with trauma and abuse • Lack of effective strategy for dealing with caretaker • High levels of stress and related hormones • Defensive exclusion of understanding of caretaker • Excessive use of dissociation and opioid related states ATTACHMENT DISORGANISATION • • • • • Poor development of internal state language Poor reflective function Deficits in empathy Contradictory representations of self and other Dysregulation of behaviour, affect and impulses NEURODEVELOPMENT & TRAUMA • Dysregulation of HPA axis functioning - stress system • Altered cortisol pattern- stress hormone • Reduced volume of hippocampus- memory • Reduced volume of corpus callosuminformation processing • Potential effects on mood and impulse control, emotional regulation TYPE 2 TRAUMA - TERR • • • • Adaptation - avoidance, repression, dissociation Repetition – re-enactment, play, identification Anxiety - arousal, aggression, self-harm Self-Concept - depression, guilt, shame CORE DEFICITS Problems with interpersonal relationships Problems with affect regulation Ongoing vulnerability to stress Self and other representations- negative self-concept, mistrust of others • Deficits in reflective function and empathy • • • • SEVERE PERSONALITY DISORDER • Syndrome of neurophysiological and psychosocial dysregulation • Symptoms as attempts to reestablish homeostasis • Basis in traumatic early attachment experiences and neurodevelopmental effects of trauma FEATURES OF BPD • Relationship disturbances • Self-destructive behaviour • Affective disturbances • Dissociation • Psychotic-like symptoms • Identity disturbances Borderline Personality Disorder - Psychological • • • • • Unresolved trauma and loss Poor reflective self function Disturbed self-experience Disorganized attachment Maladaptive defense style PERSONALITY DISORDER • Dysregulation of affect and intolerance of anxiety • Limited internal state language • Contradictory representations of self and other • Limited reflective capacity • Unintegrated traumatic memories NEURODEVELOPMENT IN PD • • • • • • Limbic irritability Reduced size of hippocampus Reduced left temporal lobe development Reduced left-right integration Reduced volume of corpus callosum Decreased blood flow to cerebellar vermis INFANT ATTACHMENT - DISORGANISED • Infant Behaviour - dazed behaviour on reunion; freezing; expressions of fear and confusion; strong avoidance followed by strong proximity seeking; attachment behaviours in confused sequence • Maternal Behaviour - confusing, frightening/frightened; history of unresolved attachment trauma, loss. TRAUMATISED AND TRAUMATISING PARENTS • Parents with unresolved traumatic attachment issues and histories of maltreatment/neglect • Range of issues and conflicts when they attempt to parent – from anxiety to avoidance to repetition • Opportunity for the prevention of disturbed parenting and abuse UNRESOLVED ADULTS features of unresolved trauma impacting on thinking and relational functioning limited RF Impacts capacity to understand and process affect and interactions Associated with limited RF and affect regulation High rates of disorganisation in borderline personality disorder ATTACHMENT AND EMOTIONAL REGULATION • Secure attachment is based on emotional attunement • Attachment relationship regulates emotional states • Emotional competence and self-regulation related to quality of early interaction EMOTIONAL REGULATION • Mutual attunement and synchronicity • Regulation of overall degree of stimulation and arousal • Promotes development of self-regulation • Process begins at birth SENSITIVITY • The ability to attune to the infant’s signals, interpret them correctly, and satisfy them promptly and appropriately. • Depends on learning the meaning of the infant’s signals as they vary over time • Different cultures value it differently • Differs from spoiling and overprotection in supporting child’s increasing autonomy and ability to communicate SENSITIVITY • Intervention studies include focused interventions in the home, and sensitivity training sessions with videotapes • They have demonstrated that parental sensitivity can be improved, by assisting them to find alternative explanations for infants’ behaviour and alternative strategies IMPLICATIONS OF EARLY EMOTIONAL TRAUMA • Attachment disruption and emotional misattunement will affect emerging capacities for interaction and self-regulation • Disruptions during critical periods and rapid phases of development are potentially the most damaging • Trauma affects brain development Neurophysiological changes • Physiological studies indicate that insecure children demonstrate high levels of stress, from suppressing or otherwise not being able to have their attachment needs met. • This may have implications for the development of psychosomatic symptoms and diseases EARLY ATTACHMENT DIFFICULTIES • Intrinsic infant problems - disorders of affective interaction • Dysregulated infant - prematurity, substance exposure, maternal stress and trauma in pregnancy, perinatal insult • Maternal attachment factors - attribution, expectations, own attachment history ATTACHMENT DIFFICULTIES • Anxiety about ability to nurture and feed the infant • Fear of harming the dependent infant • Feelings of aggression and resentment • Guilt and depression • Problems re-negotiating partner relationship • Difficulties in establishing self as mother PROBLEMS OF EARLY ATTACHMENT • • • • ANXIETY AMBIVALENCE TRANSITION TO PARENTHOOD PARTNER/SYSTEMIC ISSUES HIGH RISK ATTACHMENT PROBLEMS • Mother feels persecuted by infant and attributes hostile intent • Infant becomes identified with traumatic attachment figure/abuser • Mother experiencing effects of early trauma • Previous infant maltreatment and neglect ATTACHMENT DISORDERS • Disorders of non-attachment - emotional withdrawal, indiscriminant sociability • Secure Base Distortion - inhibition,selfendangerment, excessive clinging, hypercompliance, role-reversal • Disrupted Attachment Disorder - limited comfort from others. ATTACHMENT ASSESSMENT • Affection - sharing, warmth; absence or distortion • Comfort seeking - failure to seek comfort or seeking from strangers • Help Seeking - excessive dependence, premature competence • Cooperation - noncompliance or hyper- ATTACHMENT ASSESSMENT • Control - punitive/controlling with attachment figure; overcaring • Exploration - inhibition; dangerous exploration without secure-base behaviour • Separation and Reunion Behaviours ATTACHMENT & CHILD BEHAVIOUR PROBLEMS • Insecure attachment is not a disorder or a disturbance per se, but a risk factor • It appears associated with more behaviour problems • Avoidant children have slightly more externalising and internalising problems than secure or resistant children • Disorganised children have moderately more externalising problems & dissociative disorders ATTACHMENT PRINCIPLES AND CLINICAL INTERVENTION • The relationship between client(mother)and clinician is an attachment relationship • therapeutic bond, & the clinician as safe base, is critical to the success of intervention • Clinicians' needs to understand the mothers inner working model of attachment INTERVENTION APPROACHES • Cognitive behavioral and psychoeducational • Attachment based – importance of parental capacity to perceive and sensitively respond to child's emotional needs • Without emotional attunement parenting programs may improve management but not the emotional aspects of the parentchild relationship ATTACHMENT BASED INTERVENTION • Early intervention – antenatal, infant and toddler • Program incorporating focus on emotional development and child’s needs for attachment • Focus on improving maternal emotional availability and reflective capacity • Evidence for medium term programs ATTACHMENT-BASED CHILD THERAPY • The therapist functions as a reliable base so that a secure attachment can develop, despite the child’s attachment disorder • Through direct interaction and observation of symbolic play, the therapist enables the child to express material regarding his attachment experiences • The therapist interprets attachment-related interactions between himself and the child QUESTIONS & ANSWERS REMINDERS • Contact The ATAPS CMHS Clinical Support Service. Phone 1800 031 185 or email [email protected] • A recording of this webinar will be available on the APS ATAPS Clinical Support Service web portal - see http://www.psychology.org.au/ATAPS/networking_CMHS/ • Please complete the Exit Survey – your feedback is appreciated! • Thank-you for your participation and we hope you enjoyed it.