Support for Attachment Difficulties

Dr Venkat Reddy, Consultant Paediatrician

(With help from Lorraine Cuff Dr Therese O’Donoghue)

The role of the relational environment

Abundant scientific evidence demonstrates that

a major ingredient in this process is the “serve and return” relationship between children and

their caregivers.

Young children naturally reach out

for interaction through:

• Babbling

• Facial expressions

• Gestures

• Words

Adults respond with the same kind of vocalising and gesturing back to them

in a directive, meaningful way. This helps the infant develop a capacity

to regulate through lots of repeated experiences of being soothed in an

attuned manner.

www.developingchild.hardvard.edu

If the responses are: • Unreliable • Inappropriate • Absent

The developing architecture of the brain may be disrupted and

later learning, behaviour and health may be impaired.

The emotion regulation centres of the brain are literally hard-wired by the

experiences of distress being soothed.

https://developingchild.harvard.edu/

When the baby’s brain is soothed, it develops more receptors for oxytocin and serotonin and it develops greater connections between the brainstem, limbic system pre-frontal structures. Over time, this means that higher cortical areas can learn to

dampen down the stress response of the lower cortical structures by itself.

It has learned to do this through introjections from the attachment dyad.

“If you feel safe and loved, your brain becomes

specialised in exploration, play and co-operation. If you are frightened and unwanted, it specialises in managing feelings of fear and

abandonment.”

Dr Bessel van der Kolk

https://developingchild.harvard.edu/

If there is inadequate soothing, the baby’s brain grows very differently. The developing brain is flooded with toxic levels of stress hormones. Fewer receptors are developed

for oxytocin and serotonin. The connections between the frontal cortex and the limbic system/brain-stem are not being made as frequently. Without soothing, the baby cannot learn to sooth itself. Instead the pathway to the fight/flight/freeze neural circuitry becomes strengthened because that is what is getting the most traffic.

Factors which impact on the serve-return interactions

• Economic hardship

• Violence

• Chaotic environments

• Hunger

• Instability

• Sexual violence or abuse

• Social isolation

• Chronic disease

• Adult mental health difficulties

• Addiction

• Alcoholism

Caregivers who are at the HIGHEST

RISK for providing inadequate care often experience several of these

problems simultaneously.

SECURE AVOIDANT

AMBIVALENT DISORGANISED

Parent-infant Parent is available, protective, sensitive/responsive. Accepting consistent and predictable. Can repair damage following times of being less available and responsive.

Infant/young child Explores, experiments and learns through play. Helped to understand mental states. Emotional scaffolding helps child understand and use emotions.

Internal Working Model

Self as: lovable, effective, of interest to others. Others as: caring, protective and available; dependable, consistently responsive.

Older children

Can draw on full range of cognitive and emotional information to make sense of the social world. Good understanding of own feelings and the feelings of others. Sense of self-efficacy, self confidence and social competence. Trusts others, approaches others for help. Can resolve conflicts; self-reliant. Copes with stress and frustration. Social empathy; civic conscience.

As adults Autonomous, secure, values relationships.

Adapted from Kim Golding, highly specialised clinical psychologist.

Parent-infant

Parent is inconsistently available and responsive. Insensitive – poor at reading child’s signals. Poorly attuned and unpredictable.

Infant/young child Hyper-activation of attachment behaviour. Angry approach, fretful, crying, whining, attention-seeking, clingy, dependent. Attachment behaviour at the expense of exploration. Resist being soothed, fears withdrawal of parent. Low self-efficacy. High dependence.

Internal Working Model

Self as: unlovable, of little worth, ineffective. Others as: unreliable, not interested, inconsistent, insensitive.

Older children

Pre-occupied: alert to availability of others. Need attention and approval. Enmeshed and entangled relationships. Oscillates between loving and hating in response to parent’s behaviour. Poor concentration, easily distracted. Emotional states are transparent; emotion drives behaviour. Escalates confrontation to hold the attention of others.

As adults

Preoccupied with relationships. Low satisfaction with relationships. Jealous and possessive; coercive. Low self-reflexivity, ambivalent feelings dealt with by splitting – oscillates between viewing people as either all good or all bad. Feelings not thought through but acted out.

Adapted from Kim Golding, highly specialised clinical psychologist.

Parent-infant Rejecting, intrusive, controlling. Consistently unresponsive to negative emotion and distress. Resentful.

Infant/young child

Deactivates attachment behaviour. Inhibits emotional expression. Undemanding, compliant, self-sufficient. Exploration > attachment. Uncomfortable with closeness.

Internal Working Model

Self as: unlovable, of little worth. Others as: not available, intrusive, interfering, controlling, consistently unresponsive; consistently unavailable.

Older children

Self-reliant, independent. Achievement orientated. Cognitive development is enhanced. Emotionally self-sufficient. Distress is denied or not communicated. Low self-worth, lacks self-confidence. Shame sensitive.

As adults

Avoids intimacy. Task oriented. Emotions intellectualised. Cold and detached. Thought is seen as more reliable than feelings. Adapted from Kim Golding, highly specialised clinical psychologist.

Parent-infant Parent is frightening – dangerous parental behaviour. Frightened – alarming parental behaviour. Following frightening behaviour, does not repair damage.

Infant/young child

Fearful and helpless. Confused. Distressed and unregulated. No behavioural strategy brings care or comfort.

Internal Working Model

Self as: unworthy of care; powerful but bad. Others as: frightening and unavailable.

Older children

Fearful, angry, violent. Organise their behaviour to exert control. Controlling; avoids intimacy. Relationships cause distress with little provocation. Anxious dependence. Strong feelings are overwhelming. Cannot understand, distinguish or control emotions in self or others. Anxious and inattentive.

As adults Disorganisation remains high.

Adapted from Kim Golding, highly specialised clinical psychologist.

Trauma – ADHD overlap

Components of assessment

• personal factors, including the child or young person's attachment pattern • the child or young person's educational experience and attainment • parental sensitivity • parental factors, including conflict between parents (such as domestic

violence and abuse), parental drug and alcohol misuse or mental health problems, and parents' and

• carers' experiences of maltreatment and trauma in their own childhood • the child or young person's experience of maltreatment or trauma • the child or young person's physical health • coexisting mental health problems and neurodevelopmental conditions

commonly associated with attachment difficulties, including antisocial behaviour and conduct disorders, attention deficit hyperactivity disorder, autism, anxiety disorders (especially post-traumatic stress disorder), depression, alcohol misuse and emotional dysregulation.

Consider using the following assessment tools

• Strange Situation Procedure for children aged 1–2 years • Modified versions of the Strange Situation Procedure for

children aged 2–4 years (either the Cassidy Marvin Preschool Attachment Coding System or the Preschool Assessment of Attachment)

• Attachment Q-sort for children aged 1–4 years • Manchester Child Attachment Story Task, McArthur Story

Stem Battery and Story • Stem Attachment Profile for children aged 4–7 years • Child Attachment Interview for children and young people

aged 7–15 years • Adult Attachment Interview for young people (aged 15

years and over) and their parents or carers.

Supporting children and young people schools and other education settings

• Educational psychologists and health and social care provider organisations should work with local authority virtual school heads and designated teachers to develop and provide training courses for teachers of all levels on:

• how attachment difficulties begin and how they can present in children and young people

• how attachment difficulties affect learning, education and social development

• understanding the consequences of maltreatment, including trauma • how they can support children and young people with attachment

difficulties. • Children and young people with attachment difficulties, and their parents

or carers, • should be involved in the design of the training courses, wherever

possible.

Exclusions

• Schools and other education providers should avoid using permanent and fixed-term school exclusion as far as possible for children and young people in the care system with identified attachment difficulties.

Therapeutic interventions following child physical abuse, emotional abuse or neglect

Pharmacological interventions

•Do not treat attachment difficulties with pharmacological interventions.

Supervision consultation with health practitioner (bookable slot via

01733777911)

No further action

** Referral agreed

Referrals from Children’s Social Care ONLY

Referring social worker invites parent/ carer/ school/ supervising social worker etc. for initial consultation

appointment at Child Development Centre

Further intervention plan established during initial consultation appointment

Further individualised consultations with carer(s)/residential staff/school/social care

1:1/2:1 psychotherapeutic intervention

Twelve-week Nurturing Attachments Group (x3 groups per year)

Recommendation to child’s

social worker

Children’s Social Care Permanency Team

Discharge

Disch

arge

1. Supervision consultation with social worker bookable via Children’s Social Care BSO

Training need identified

Group Supervision/Reflective Practice

x1 per month

Training workshop offered

Further specialist assessment

**referral form required

Peterborough Fostering and Adoption Clinical Psychology Service Pathway

PH

ASE

2

PH

ASE

3

PHASE 1

Training seminar with school/social care/ residential staff

Discharge

What do we need?

• Scoping current commissioning and provision against NICE guidance

• Multiagency Training

• Public health evaluation of Routine enquiry into ACES

• Co-ordination of existing services: Universal services, Perinatal mental health, Family Nurse Partnership, Targeted Youth Services, Forensic CAMHS

Most urgent service need

• Interim agreed pathway for children presenting with emotional dysregulation without core mental health or neurodevelopmental problems who are exposed to ACES and likely to have attachment difficulties

Thanks

Any Questions?