Trauma and Attachment Disorders pdf
Trauma and Attachment Disorders pdf
Exposure to stressors can have an impact on day to day functioning. In order for a stressor to be considered traumatic, the symptoms must cause clinically significant distress. All trauma disorders share one feature in common: an extremely stressful event or series of stressful events. The group of trauma disorders described here are classified as “Trauma and Stressor Related Disorders” in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
This trauma category includes a number of disorders that are marked by significant stressors in life. Here, we wish to introduce a few disorders that may occur in children or teenagers. These are Posttraumatic Stress Disorder (PTSD), Adjustment Disorder, Reactive Attachment Disorder and Disinhibited Social Engagement Disorder.
PTSD: involves exposure to actual or threatened death, serious injury or sexual assault that results in a number of lasting and damaging symptoms to be discussed below.
Adjustment reaction: is a prolonged reaction to a stressor resulting in emotional and/or behavioral symptoms. Unlike PTSD this stressor may be more commonplace like divorce, illness within the family or a significant move. The stressor is less serious than PTSD but results in lasting symptoms beyond what would be expected in the situation.
Attachment: involves exposure to a stressor happens very early in life or prenatally and impacts a child’s ability to bond with a parent. This disrupted bond results in disorganized and dysregulated “push/pull” behavior. Push/pull means that a child’s connection to a caregiver can be close one second and rejecting the next. Sometimes push/pull or quick attachment is seen with other adults the child engages with. Children who have attachment disorders were not able to establish and close, trusting and consistent bond with caregivers in infancy.
Sometimes even in the instance of children adopted at birth, the prenatal experience, including maternal stress and/or drug and substance use, is traumatizing to a child and causes attachment challenges even when the child has been adopted at birth by warm and consistent parents. Attachment disorders can include overly familiar behavior, Disinhibited Social Engagement Disorder, or distant and rejecting behavior, Reactive Attachment Disorder.
PTSD – This disorder is diagnosed when an individual experiences, directly witnesses or hears about a close friend or family member’s serious injury, threatened death, someone else’s death or sexual violence. A first responder to tragedy may also experience PTSD. Symptoms include intrusion symptoms like recollections, flashbacks or nightmares causing distress, avoidance of thoughts, feelings and reminders of trauma, alterations in cognition and mood (inability to remember, blaming yourself, negative emotions) and changes in arousal and reactivity that include anxiety and hypervigilance, irritability and problems sleeping or concentrating. This disorder can occur from childhood all the way to adulthood. Symptoms must be present for over a month and cause clinically significant distress.
Adjustment Disorder – symptoms include depression, anxiety and/or disturbed conduct that occurs in reaction to a stressor and does not represent bereavement symptoms. A stressor could be a move, birth of a sibling, divorce, or a school change as well as many other stressors that do not meet criteria for a PTSD stressor (not serious injury, threatened death or sexual violence). This disorder can occur from childhood to adulthood. Symptoms must cause clinically significant distress.
Reactive Attachment Disorder – symptoms include avoidant behavior socially, aggression, unpredictable interactions with others that may quickly shift from familiar and comfortable to angry and rigid, children can be uncooperative and challenges are based in mistrust of adults that results from the early, even prenatal experience of stressful exposures, and lack of consistent and predictable caregiving. Very loving parents who are in the midst of a violent and contentious separation and divorce, a single parent with little support and an unpredictable work schedule who must pass the young child from relative to relative, parents who suffer from depression or addiction, all of these well-meaning parents may have a child who struggles with attachment. Additionally children who are abused or mistreated, spend time in the foster system, have parents in jail, any child who is not able to form a stable, trusting, predictable relationship with caregivers may suffer from issues related to attachment. International adoptions that take months or years to finalize, children who go from having minimal care and support to joining a loving family may have attachment challenges because the first months or years of life were challenging and unpredictable.
Disinhibited Social Engagement Disorder – is an attachment disorder marked by overly familiar behavior with adults. A child may have a push/pull interaction with his or her own caregivers and then cling to the friendly parent at the pool, walk up to the neighbor’s door and invite him or herself in, meet a substitute teacher and ask to come over to her house on the weekend. DSED is marked by overly familiar behavior and tendency to attach very quickly to anyone. These behaviors can fluctuate with RAD behaviors for some children. Attachment Disorders tend to be diagnosed in children age 5 or younger. When children get older often attachment challenges manifest into behavior disorders, mood disorders or personality disorders. Attachment could be at the root of challenges your teenager experiences but he or she will not necessarily be diagnosed with RAD as an older child or teen.
For Attachment- Filial Therapy, Play Therapy, Parent Consultation with secondary ABA Therapy for behavior if needed. For young children play therapy utilizes toys and art allowing a child to express feelings and experiences by acting them out. Guided play therapy can introduce coping skills and emotional awareness into play themes. Filial Therapy is a type of play therapy that includes parents with the belief that parents can engage with their children therapeutically and be an agent for change in the family relationship and dynamic. Parents are encouraged in this model to be accepting and supportive of their children. Allow children to feel heard and feel like they have choices. Expect respectful behavior but ask for this nicely and stay close to the child if he or she is upset. Be sure needs of safety, hunger, bathroom are all met. Provide praise and support when you see behavior you like and don’t reinforce with attention behaviors that are aggressive. Parents will find it helpful to read “The Connected Child” by Karyn Purvis. She was a researcher and clinician who specialized in attachment throughout her long career at TCU.
ABA therapy can be a secondary support for families who are receiving attachment based treatments above. Some families may need in home behavior support to identify how to reinforce good behavior, know what behaviors to ignore and handle the challenging outbursts a child may have. An ABA provider will need to understand the full diagnostic picture and work in collaboration with the filial therapist who specializes in childhood trauma and attachment. Attachment can be very hard to treat and seeking help early is essential.
For Trauma- Internal Family Systems Therapy (IFS) and Eye Movement Desensitization and Reprocessing (EMDR):
Two treatment modalities that show success in treating trauma are IFS and EMDR. Typical CBT interventions are not recommended for significant trauma as they do not have evidence to support efficacy. These models of therapy both require intensive training on the part of the clinician. Doctoral level and LPC clinicians can seek training for IFS or EMDR. If seeking these therapies from a provider ask your provider about their credentialing. Internal Family Systems Therapy is rooted in understanding one’s parts and working to understand exiled parts that may be angry, scared, or traumatized. IFS uses systems theory and postulates that we can achieve balance and harmony within our own internal systems, healing the imbalance that trauma causes. www.selfleadership.org is the official IFS website. EMDR is treatment that uses bilateral stimulation to help the brain process traumatic memories differently to promote healing. www.emdr.com provides more information about this modality of treatment.
For Trauma- Secondary to Trauma treatments noted above, therapists may incorporate Mindfulness. Mindfulness involves recognizing and accepting feelings and allowing them to just be. This practice involves scanning the body to notice tension and working to let that go. Awareness of the present time and accepting thoughts and feelings are important in Mindfulness.
Relaxation and Meditation. Breathing and relaxation are encouraged in mindfulness and can make a big difference in reducing anxiety and the presence of negative, distorted thoughts.
Accepting Thoughts. Mindfulness focuses on acceptance and not the immediate push to criticize ourselves.
For Adjustment Disorders: As these by definition are mild in comparison to trauma or attachment disorders, short term solution focused therapy, Cognitive Behavioral Therapy (CBT) and mindfulness interventions may be helpful. Working on recognizing emotional states, accepting emotions, developing coping strategies and communicating about emotions in an effective way with others can help children and teens with adjustment challenges.
Many tests and measures may be part of a psychological evaluation to determine whether trauma or attachment are relevant diagnoses and to better understand the contributing factors. This can be hard with children who are sometimes less able to report directly. Some children are very unaware of their own feelings. Using a mix of parent report, self-report, observation and projective measures is often helpful.
Projectives. Questions, open ended sentences, drawing tasks can allow a child to express emotions and experiences indirectly. Themes can emerge related to worry or rejection and some insight may be derived from the collection of these measures about trauma experiences.
Story Telling. Tests like the Roberts or TAT involve presenting story cards to an individual and having him or her tell a story about the vague card. Again themes and emotional content is noted as well as support of self and support from others.
Rating Scales. Sometimes it is easier for children to express feelings by answering questions. Parents and teachers can also complete questionnaires to provide a sense of how each child appears and performs in different settings. This adds to the data since an evaluation is conducted in one setting that is not natural to the individual.
Play observation. Watching a child play with toys can provide insight into feelings and experiences by attending to themes introduced by the child.
Observation during testing. Looking for overly familiar or frightened behavior, push/pull interactions, quickly shifting, disorganized or irregular behavior, noting affective states of the body that indicate tension or discomfort, body language and noting interactions with examiners can provide insight.
Detailed family history. It is important to understand what a child has experienced including information about the family system to put behaviors and emotions into context.
Executive functioning and processing speed measures. It may be helpful to see how traumatic events are impacting a child’s ability to learn and process information. Other neuropsychological measures assessing cognition and academic achievement could give further insight into strengths and weaknesses and the impact of trauma or stressors on the child.
WHERE TO GO FOR HELP WITH TRAUMA
A referral for a comprehensive neuropsychological evaluation may be warranted to confirm diagnoses and work to better understand your child’s strengths and weaknesses. This type of assessment includes evaluation of cognitive ability, adaptive skills, language skills, social skills, and emotions. Other areas may be evaluated as concerns arise. Referrals may include psychotherapy, group therapy, parent consultations, an IEP or a Section 504 plan.
For Therapy referrals see treatment above.
School Services. School-based supports like an IEP or Section 504 plan can help your child receive accommodations and modifications that they may require to access learning in the classroom setting. Taking a comprehensive neuropsychological report any of these professionals will help them to get an understanding of your child. It’ll be important to think about how these therapies fit together and how different skills are being built and addressed to best support your child. Anxiety and behavior challenges resulting from attachment and trauma can impact school performance and social skills. Individual meetings with the school counselor or school psychologist may provide emotional support, assignment of a peer buddy or mentor at school can help as positive event scheduling, a lunch bunch or social group may also help build peer support. In order to write a formal plan your school team will need to find that there is an educational impact of trauma symptoms in some aspect of your child’s education.
It may be easier to obtain support through a Section 504 plan if your child’s grades and test scores are not at all impacted. A 504 Plan requires a medical condition that impacts functioning but academics and test scores need not be directly impacted. An IEP is a more detailed document that does require clear educational impact of symptoms. In addition to emotional supports goals in an IEP would also address challenges in reading, writing, math or communication. Ask your school about both an IEP and a 504 to determine which would best serve your child.
Psychiatrist. Sometimes children with trauma related diagnoses do take medication prescribed by a psychiatrist. Keep your pediatrician in the loop about your child’s mental health and request a referral to a child psychiatrist to learn more about the benefits and side effects of medication if your child’s symptoms are not appropriately alleviated in therapy or if the severity of symptoms constitutes a multimodal approach.
Trauma and Attachment Disorders can be very challenging to treat. Do not lose hope. Work with professionals, seek outside support from friends and family, find a support group and be patient with yourself. Taken together, it is valuable to obtain a diagnosis and engage in the appropriate therapies as early as is feasible. With these supports in place, it is possible to see improvement in symptoms, development of a strong internal system of support, increase engagement in life, experience fewer physical symptoms, develop better coping skills, and have the potential to live a happy life.
 Purvis, Karyn B., & Cross, David R., & Sunshine, Wendy Lyons (2007). The connected child: Bring hope and healing to your adoptive family.
 Seigel, Daniel J. & Bryson, Tina Payne (2014). No drama-discipline: The whole-brain way to calm the chaos and nurture your child’s developing mind.
 Dewdney, Anna (2007). Llama Llama mad at mama.
 Greene, Ross W. (2001). The explosive child: A new approach for understanding and parenting easily frustrated, chronically inflexible children.
 Siegel, Daniel J. & Bryson, Tina Payne (2012). The whole Brain Child: 12 Revolutionary Strategies to Nurture your Child’s Developing Mind.
 EMDR website
 IFS website
 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)