The Impact of Attachment Trauma on

Child Development

Creating Connections to Shining Stars

Virginia Beach 17 July 2012

Jane C. Probst, MSW

Rappahannock Rapidan Community Services

Child & Family Clinical Services

jprobst@rrcsb.org

OverviewExpanding Perceptions of TraumaChildhood Trauma: Early Lessons Last a LifetimeDiagnosing Childhood Trauma: DSM IV Criteria Existing

DiagnosesTrauma Researcher’s DSM V Proposals - Thinking

DifferentlyDSM V Considered Diagnoses Changes – May 2013Why Diagnoses Matter Adverse Childhood Experiences Study (ACE) ACE Adult Findings ACE Co-Morbid GroupsChildhood into Adulthood OutcomesFind Your ACE Score - PDF Score SheetWhy Diagnoses Don’t Matter Considering Trauma Treatment References & Recommended ReadingsQuestions & Comments

Expanding Perceptions of TraumaNatural Environment Traumas

Hurricanes, Earthquakes, Volcanoes, Floods, Fires - Random Transportation Traumas

Vehicular Accidents: Land, Sea, Air - RandomCommunity Violence

Terrorist Attacks - RandomWar, Ethnic & Cultural Discrimination – Time and place

specificPersonal Violence

Stranger Danger, Assaults, Robbery, Sexual Assault/Rape – Random

Interpersonal Violence Domestic Violence, Partner Abuse, Intimate Partner ViolenceOccurs within the context of a relationship and is time-relative

Attachment Trauma and Early Childhood TraumaAge of onset of trauma & trauma symptoms are inversely

correlatedThe younger the age of onset, the more complex the cascade

of symptoms

Actually, on a cellular level, I’m very busy…

Infants are born with their fully developed & largest sensory organ – skin! And ready to receive the initial stimulus to begin building neural connections.

Childhood Traumas: Early Lessons What is Attachment and Attachment Trauma?

Secure or Insecure Attachment, Internal Working Model Mother/primary caregiver is infant’s whole world Reciprocal & symbiotic self-regulate emotions & return to homeostasis

Infants 1st job is to regulate body temperature and functions at birth AT is chronic, accumulative, and compromises learning “Inversely related to the age of onset of first trauma, such that those with early life

trauma are more likely to manifest” and accumulate symptoms throughout the lifespan. (van der Kolk et al., 2005)

Natural trauma survival response options in “limbic animals” Fight: infant has no physical power over abuser Flight: source of safety is source of abuse/neglect place child in a double bind Freeze – only option available to infants & children

Restricted brain development & integration in “freeze” state; flooding & restriction of hormones

Lesson learned to numb – set up for later maladaptive coping Pronking – exhilarated leaping into the air when contact with predator avoided

Defensive mechanism, warning to others of danger, exhilaration at survival

Polyvagal Theory 10th cranial nerve: evolution of Sympathetic & Parasympathetic NS (Porges, 2011)

Emotional & physiological regulation synchronized with internal organ regulation Bidirectional signals: 80% afferent (incoming) 20% efferent (outgoing).

Childhood Traumas: Early LessonsBirth to 18 m. predominate right hemisphere

development Implicitly learned recognition: facial features, tone of

voice, incidental environmental cues Incidental verbal/non verbal cues to the safety/danger

from caregivers & environmentEarliest implicit memories form outside awareness and

become hard-wiredMirror neurons reciprocate all emotions, not just 6 we’re

born with Teaches emotion and self-regulation simultaneoulsy

Neurons that fire together, wire together (Hebbs, 1949) The initial seeds of sympathy and empathyFacial expressions, tone of voice, heart and breath rates

model regulation or dysregulation

Diagnosing Childhood TraumaPTSD: Anxiety Disorder w/Discrete Event – Not a Child

Focused Dx DSM-V change PTSD to Trauma & Stressor Related Disorders –

child focused Ignores accumulative layers of chronic trauma, abuse & neglect

Disorder Extreme Stress Not Otherwise Specified - DESNOS Captures complex trauma symptomatology Not recognized by APA as a diagnosis, however clinicians use it as

specifierReactive Attachment Disorder

Does not consider trauma outside of attachment with caregivers Many professionals consider it an inaccurate diagnosis > 8 y.o.

Multiple Co-Morbid I, II, III Dx Diagnostic behaviors are very disorganized & dysregulated;

diagnoses difficult ADHD, Bipolar, Conduct Disorder, ODD, Intermittent Explosive

DisorderAccurate assessments for early interventions

Critical learning periods are interrupted/disrupted/mitigated Cascading impairments are accumulative and undeterminable Restricts neural development, accelerates pruning

Researcher’s DSM V Proposals Developmental Trauma Disorder (van der Kolk, 2005)

Comprehensive criteria targeting children Under consideration by APA for DSM V Field trials ongoing ; criteria info at www.traumacenter.org

Disorders of Extreme Stress NOS – DESNOS Not accepted by APA but used as a ‘qualifier” Can be Co-Morbid with PTSD Diagnosis Different criteria from PTSD

PTSD - Organized Attachment (Classen et al., 2006) Rejected Caregiver is not the abuser, however, caregiver is not protective Poverty, DV, substance abuse, chronic A & N by others Invisible, Parentified, Secretive Hiding in plain sight

PTSD - Disorganized Attachment (Classen et al., 2006) Rejected Caregiver is the abuser Significant affect dysregulation Narrow window of tolerance Approach-avoidant behaviors: caregiver is abuser

DSM-V APA Considered DiagnosesTrauma & Stressor Related Disorders: All

AgesReactive Attachment Disorder, child is > 9 months

A & N by caregivers, incidental social cues of contempt & disregard

Disinhibited Social Engagement Disorder > 9 months Multiple caregivers, indicative of children in chronic foster

carePTSD in Preschool Children < 6 years oldAcute Stress Disorder (no age limiting criteria)Adjustment Disorders

Current subcategories with additions (PTSD/ASD symptoms)

Other Specified Trauma/Stressor Related DisorderUnspecified Trauma/Stressor Related Disorder

No criteria determined at this time for either of the above

Developmental Trauma Disorder (van der Kolk, 2005)

For diagnoses & criteria info: www.dsm5.org

Why Diagnoses Matter ATTACHMENT & ATTACHMENT TRAUMA HAPPEN AT CELLULAR LEVEL

Implicit memory begins in utero and is hard-wired Inability of integrated narrative ability – left & right brain integration Restricts critical periods of brain structure development & myelination Stress hormones (cortisol, adrenalin, norepinephrine) flood brain/body Body/brain develop with a baseline of stress hormones Baseline lasts a lifetime without intervention. Body regulation through CNS is infant’s main job from birth

Identify Dx for prevention, intervention, and treatment Formulation & Implementation of Ethical MH Policies for Children Attachment Styles are Generational (Hesse, 1999)

75% correlation attachment styles between generations (Schore, 2000) Intervention reduces generational cycles of chronic abuse USDHHS (2002) – identified 870,000 abused/neglected children in US 83.3% abused by primary caregiver Infants to age 3 with highest rates of victimization and death

Research for evidence based treatments All Axes considered for holistic functioning Mental health: neurobiologically, physiologically, and medically necessary for survival Attachment Theory - Darwin meets Freud!

ACE Longitudinal Study1998 Kaiser Permanente & CDC

Adverse Childhood Experiences – ACE (n=13,494)Identified 7 categories of abuse (self-reporting)

Substance abusing family member – 25.6%Sexual abuse – 22%Mental illness of caregiver – 18.8%Violence against the mother – 12.5%Psychological Abuse -11.1%Physical Abuse - 10.8%Family member incarcerated – 3.4%

Poverty & economic risk factors not considered

In depth outcome details: www.acestudy.org

ACE Adult FindingsSubstance Abuse family member exposed to other category (N=2064)

Mental illness of caregiver – 34%Sexual Abuse – 34%Violence against the mother – 29%Psychological Abuse – 22%Physical Abuse – 19%Family member incarcerated – 8%

Violence against mother exposure other category (N=1010)Substance abusing family member 59%Sexual Abuse – 41%Mental illness of caregiver – 38%Psychological Abuse – 34%Physical Abuse – 31%Family member incarcerated – 10%Witnessed assault with knife or gun – 3%

(Felitti et al., 1998)

Groups ≥ 4 of 7 Self-ReportAny combination of 4 or more groups:Depression for 2 weeks in past year –

50.7%Illicit drug Use – 28.4%No leisure time/activity – 26.6%Suicide attempts – 18.3 %Smoking - 16.5%Self identified alcoholic – 16.1%Obesity - 12%≥ 50 Sexual partners – 6.8%STI’s – 6.8%

Childhood to Adulthood Health OutcomesACE Adult Health Outcomes Studied & Published:

Chronic Disease: Lung Cancer, Heart Disease, AutoimmuneHealth Risks: Alcohol & Drug Abuse, Obesity, Smoking Mental Health: Depression, Suicidality, Work AbsenteeismVictimization & Perpetration: Intimate Partner ViolenceSexual Behavior: Fetal Death, Teen Pregnancy, STD’sAutobiographical Memory Disturbances

Impaired implicit and narrative memorySpecial Populations Studies

Child Sexual Abuse Victims, Children of Alcoholics, War Refugeeswww.cdc.gov/ace/outcomes.htm

Strong Correlations Between Attachment Trauma & PD75% of BPD are women (DSM-IV-TR, 2000) w/history of multiple

AT Insecure attachment risk factor for PTSD severity in veterans

(Renaud, 2008)

Finding Your ACE Score092406RA4CR

While you were growing up, during your first 18 years of life:

1. Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? orAct in a way that made you afraid that you might be physically hurt?Yes No If yes enter 1 ________

2. Did a parent or other adult in the household often or very often…Push, grab, slap, or throw something at you? orEver hit you so hard that you had marks or were injured?Yes No If yes enter 1 ________

3. Did an adult or person at least 5 years older than you ever…Touch or fondle you or have you touch their body in a sexual way? orAttempt or actually have oral, anal, or vaginal intercourse with you?Yes No If yes enter 1 ________

4. Did you often or very often feel that …No one in your family loved you or thought you were important or special? orYour family didn’t look out for each other, feel close to each other, or support each other?Yes No If yes enter 1 ________

5. Did you often or very often feel that …You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? orYour parents were too drunk or high to take care of you or take you to the doctor if you

needed it?Yes No If yes enter 1 ________

Finding Your ACE Score6. Were your parents ever separated or divorced?

Yes No If yes enter 1 ________

7. Was your mother or stepmother:

Often or very often pushed, grabbed, slapped, or had something thrown at her? Or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Or Ever repeatedly hit at least a few minutes or threatened with a gun or knife?

Yes No If yes enter 1 ________

8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

Yes No If yes enter 1 ________

9. Was a household member depressed or mentally ill, or did a household member attempt suicide?

Yes No If yes enter 1 ________

10. Did a household member go to prison?

Yes No If yes enter 1 _______

Now add up your “Yes” answers: _______ This is your ACE Score.

Higher the score, higher the risk consequences of Adverse Childhood Event

(Felliti & Anda, 1998)

For ACE Score diagnostic tool in Spanish, French, Icelandic, Norwegian, & Swedish

http://www.acestudy.org/yahoo_site_admin/assets/docs/ACE_Calculator-English.127143712.pdf

Why Diagnoses Don’t Matter1st Rule - DO NO HARMConstellation of Symptoms = Constellation of Treatments

Individualized with engaged client Sequenced and strength-based

Safety, Stabilization, skill building, therapeutic alliance, Trauma processing, narrative integration, meaning of self identity

Psycho-education to normalize symptomatology Bottom-up and top-down treatments

Build Therapeutic Alliance Regardless of Diagnoses Attachment repair, mirror neurons, holding environment Darwin meets Freud! Affect & Physiological Regulation (physical and emotional

regulation) Widen the window of distress tolerance Recounting trauma can re-traumatize – vicarious trauma

considerationsImpaired Integration & Transition of Developmental

Stages Implicit memories & narrative abilities - consider developmental

age of client Critical learning periods: affect regulation, language,

concrete/abstract thinking

Considering Trauma TreatmentsTreatment and assessment are ever-evolving

Circling back to crisis & stabilization with newly acquired skills Interventions can be in the moment – trusting the client! Clinical agility and attunement

It’s never one thing…… Chemical reactions are cascades of reactions & catalysts People are walking talking feeling emoting chemical reactions Emotions are necessary physiological processes dependent on the CNS Treatments focus on outcome may miss the “Lessons Learned”

Developmental age vs. chronological age Meet the client developmentally Under stress we regress (stunted affect, dysregulated behaviors, etc.) Cyclical groundwork

Attachment, Attunement, Alliance & Affect Regulation Trust your client to give you metaphors & analogies

Psycho-education of CNS normalizes trauma sequelae Panic attacks, nausea, somatization Parasympathetic NS versus Sympathetic NS

Considering Trauma Treatments Connection & vulnerability – taking worthwhile risks

Brené Brown www.tedtalks.com (20 minute video) Neuroplasticity: positive physical activity integrates experiences

Simultaneous regulation through combined sequenced therapies Top-down (cognitive talk-based) & Bottom-up (experiential) therapies Cognitive Processing Therapy – structured 12 sessions includes writing CBT with Prolonged Exposure EMDR – Eye Movement & Desensitization & Reprocessing adults &

kids Sensorimotor Psychotherapy – mind/body/spirit (Pat Ogden) Attachment, Self-Regulation & Competency – ARC

Margaret E. Blaustein & Kristine M. Kinniburgh (2010)

Experiential learning through repetition rewires brain Procedural memory strengthens (long-term & implicit) Integrate implicit and explicit memories to narrative change of IWM Client is focus, not the trauma

Questions-comments-contributions-insights?

References Ahrens, J., & Rexford, L. (2002). Cognitive processing therapy for

incarcerated adolescents with PTSD. Journal of Aggression, Maltreatment & Trauma, 6(1), 201-216.

Axelrod, S. R., Morgan, C. A., & Southwick, S. M. (2005). Symptoms of posttraumatic stress disorder and borderline personality disorder in veterans of Operation Desert Storm. American Journal of Psychiatry, 162, 270-275.

Blaustein, M.E., Kinniburgh, K.M. (2010). Treating traumatic stress in children and adolescents: How to foster resilience through attachment, self-regulation , and competency. New York, Guilford.

Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73(5), 965-971.

Classen, C. C., Pain, C., Field, N. P., & Woods, P. (2006). Posttraumatic personality disorder: A reformulation of complex posttraumatic stress disorder and borderline personality disorder. Psychiatric Clinics of North America, 29, 87-112.

Courtois, C. (2012, February). New Guidelines for the treatment of complex trauma, Chevy Chase, Md.

Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., & Marks, J.J. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4). 245-258.

REFERENCES Heller, D. P. (2012 February) The neurobiology of relationships: Crossing the

bridge to secure attachment and to regain resilience and richness in relationships. Washington, DC

Hesse, E. (1999). The Adult Attachment Interview: Historical and current perspectives. In J. Cassidy & P.R. Shaver (Eds.), Handbook of attachment: Theory, research and clinical applications (pp.395 – 433). New York: Guilford Press.

Jankowski, M.K., Leitenberg, H., Henning, K., & Coffey, P. (2002). Parental caring as a possible buffer against sexual revictimization in young adult survivors of child sexual abuse. Journal of Traumatic Stress, 15(3), 235 – 244.

Johnson, D. M., Sheahan, T. C., & Chard, K. M. (2003). Personality disorders, coping strategies, and posttraumatic stress disorder in women with histories of childhood sexual abuse. Journal of Child Sexual Abuse, 12(2), 19-39.

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REFERENCES Luxenberg, T., Spinazzola, J., Hidalgo, J., Hunt, C., & van der Kolk, B. A.

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Owens, G. P., & Chard, K. M. (2006). PTSD severity and cognitive reactions to trauma among a college sample: An exploratory study. Journal of Aggression, Maltreatment & Trauma, 13(2), 23-35.

Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication , self regulation. New York, W.W. Norton.

Renaud, E. F. (2008). The attachment characteristics of combat veterans with PTSD. Traumatology, 14(3), 1 – 12.

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Singer, J. B. (2009). Cognitive-Behavioral therapy. In A. R. Roberts (Ed.), Social worker's desk reference (2nd ed., pp. 742-747). New York: Oxford

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