Attachment Disorder and Symptoms in Adolescents

Reducing fear, shifting thinking and promoting belonging for teens with attachment disruption and trauma

Visible Child Initiative Training SeriesJuly 22, 2014

Presenter:Krista Nelson –LICSW LMFT Wilder Foundation Attachment and Trauma Training Program krista.nelson@wilder.org / 651-280-2624

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“It is the space between individuals that really matters,

the nature of attachments”

David Brooks- New York Times

The Visible Teen in our Programs

Adolescents in Housing Crises• Within every young person

is a story of how she has come to be here

• Often, a core part of that story involves loss of protective adults and a perceived need to survive on one’s own, ready or not

• Each has an attachment story

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Attachment Is…

• Evolution’s way of maximizing survival in a dangerous world- can’t survive alone

• Hard wired quest to stay close to other whom you have enduring emotional ties. Stress activates need to seek out/engage/get relief.

• A dance of “call and response” creates a neural, life long map for how to manage feelings & be with others

• Provides secure base from which to explore and learn about world, across cultures

• Base for surviving terror, helplessness- haven for healing, making sense, resilience – trauma prevention

John Bowlby- “Attachment is an emotional, survival driven tie to a specific person or persons that endures across space and time.” 1969

• 44 Thieves- Real life experiences of how caregiver deprivation shapes current behavior.

• “The young child’s hunger for his mother’s presence and love is as great as his hunger for food”.

• Shifted the mental health paradigm -emotional accessibility and responsiveness builds health- loss, isolation creates harm

• “Dependency is an innate part of being human, rather than a childhood trait we outgrow”

• Today’s neglected children become tomorrow’s neglectful parents

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Stress• The emotional and

physiological reaction to a threat, whether real or imagined, results in a series of adaptations by our bodies

• Stress keeps us out of relationship with one another.

• Attachment is about coping through stress

Parent Responsiveness- “Synchrony”

• Predicts security in infant, self regulation in the two year old and moral orientation and empathy in the teen

• Father son tumble play linked to lower aggression in 2-6 year olds

• Mother- teen talking linked to depression reduction and increased social savvy

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How the brain forms…

• What the mother experiences the baby experiences.– Excitement– Hope– Joy– Dread– Overwhelming stress– Chemical use

Neurological Patterning“The Brain is a Pattern Seeking, Meaning Making Machine”

• Caregiver remains with infant in face of increasing levels of arousal (too much activity) and helps make arousal tolerable.

• Exchange of pleasure, joy generates Oxytocin which modulates cortisol levels. Brain learns to organize this energy.

• Sets template for how such interactions feels to infant and are coded in implicit memory.

Cycle of Need in Infancy

Child B

Cue or Miscue Needs?

Cycle of “Want” in Toddler Years

• Takes in image of self from caregiver’s mind

• Learns to make sense of what he experiences through experimenting and checking back (Are you there?)

• Integrates “constancy”- You are mean and you are still Mom

• NO! I do it!

Teen Years• Do best with a “secure

base” from which to explore and a “safe base” to call upon when distressed

• At times, actively avoid relying on parents when stressed- learning to not get needs met by adult

• Sometime seeks parent to “co-regulate” intense emotion

• Parent can assist with “life script” – Who am I?

Attachment security provides the developing child….

• Capacity to reflect on own states and make meaning, not just be the state- This is “Mentalizing” “I am disappointed because…”

• See that what I am feeling can be different from what you are feeling and that what I do affects you- Seeds of Empathy

• Sets up core beliefs about who am I and who others can be to me- Seeds of Self esteem and Trust

• Core lens for interpreting my own or other’s behavior

Life Skills Learned in Attachment Relationships

• I can calm my body down when I am upset.• I can figure out what to do when I am bored.• I can ask for help if I need it.• I can see how my actions effect another.• I can stand being frustrated as I take on new

challenges.• I can hear “No” and shift gears, even when I want to

keep doing what I am doing.• I can survive hard times.• I know that I am connected to others and this brings

feelings of calm, sometimes joy.

Regulation Partnership

• When child has someone who helps them manage what is overwhelming, that child can begin to explore her world through trial and error, take risks and form a coherent view of self and the world.

• Resilience is the ability to respond adaptively to challenge, strengthened by tie to at least one other

Insecure Attachment PatternsFunctional way to get needs met from relationship you got

• Avoidant child• Ambivalent child • Disorganized child

• Dismissing teen– Preoccupied teen– Unresolved teen

• And yet- not fixed• Parents can overcome

histories of trauma and poor attachment- change their approach towards own child

Who Did This For You?- Life Script• Think of five words to describe

your parent(s) when you were a kid.

• Think of an example that illustrates these five words from your memory.

• What adults were you closest to and why?

• What would your parents do if you were upset, sick, distressed?

• Why did they act the way they did?

• Are you close to your parents now?

An attachment lens organizes what we see and help us determine where to go……

Consider…•What happened between this teen and his caregivers, especially age 0-3 as his brain was forming?•How does teen move from stressed to calm or frustrated to able to act? Who modeled this for him?•How does teen feel safe? Can he hold this feeling of safety in different settings?•Who is teen socially? Can he form ties? Can he ask for help? Can he help others?•Can this teen step back and reflect on his actions, “think aloud”?

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Thinking of a Child with Attachment Trauma

• “I don’t need anyone. I am alone”• “I need to be exactly what you need, to know I

am okay. I don’t exist if you aren’t in sight.”• “People always leave me”• “I am going to die when I feel- can it end?”• “I always mess up- People expect me to be

perfect”• “No one is safe. I am not safe.”

Tasks of Teen Complicated by Attachment Insecurity/Trauma

• Seek sexualized touch for belonging• “All about me” survivor brain• Lying, stealing, tantrums taken to new levels with stiffer

consequences• Self sabotage in school and activities• Unresolved grief from past attachment ruptures• Accepting “no” is submission, loss of control• Adults have been both comfort and source of fear• Feel most alive when in negative interaction• Acting out, like shoplifting can actually be a cry for some

response- “see me”

Teens with early histories of chronic stress and attachment loss

If we can’t reduce our stress internally,

we automatically seek to calm stress externally

in how we act with others

What has been the nature of your teen’s attachments?

• What kind of “regulation partnership” has she had with adults with responsibilities to guide and protect her?

• Does he move closer or farther from others when in need?

• Does he get his needs met from whomever is present, “anyone will do”?

• Has she lost trust that people matter?

• What kind of “protective skin” do you see?

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Adverse Childhood Effectswww.ACEstudy.org

• Link between childhood toxic stress and chronic diseases people develop as adults

• The more ACES- see disrupted neurodevelopment, social emotional, cognitive impairments, adoption of health-risk behaviors, early death

• Ten types of toxic stress events: – Emotional, sexual, physical abuse– Emotional and physical neglect– Parent addicted to alcohol/drugs– Seeing caregiver abused– Family member in prison– Family member with mental illness– Parent who had disappeared – left or divorced

“Ace” score- 70% of 17,000 in study had at least one

Lifetime Consequences

• Understanding Relational Trauma’s Impact: “ACEs Too High”

Paradigm Shift

Traditional View• The client is

oppositional, defiant and manipulative.

• The behaviors are the client’s way of controlling everyone around them.

New View• The client is in a highly

anxious, stressed state of fear.

• The behaviors are the client’s attempt to reduce the fear and stress in order to feel calmer.

What Labels do the Teens you know already carry with them?

• Bad kid• Manipulative• Lazy• Violent• User• Drifter

• ADHD• ODD• Conduct Disordered• PTSD• RAD• FASD

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Mid-range emotion and self regulation

Regulation is balanced flow of energy and information throughout systems of brain

TriggerTrigger

Aro

usal

Aro

usal

Mid-range emotionMid-range emotion

New

Learning

New

Learning

BalanceBalance

Hypo arousal- hyper arousalWhen children experience too much fear and “check out.”

Habitual Movement of Brain Stress overrides Cortical brain

TriggerTrigger

Aro

usal

Aro

usal

Mid-range emotionMid-range emotion

Dissociation

Dissociation

New

Learning

New

Learning

BalanceBalance

•Ann Gearity, Making the most out of milieu treatment

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Hyperarousal:Flight/fight response

Optimal arousal: Social engagement

response

Hyporarousal:Immobilization

response

Window of tolerance

Many children with difficult and severe behaviors live in a perpetual state of distress. “Their high

level of distress distorts their perception of the world and keeps them living in a state of fear. With this understanding, it becomes clear that in actuality,

their behaviors are perfectly normal –normal considering their internal state of distress.

It is just that it is their normal, not our normal. “ Forbes, p.33

Arousal:It’s Physiological!

Diagnosis and Insecure Attachment • Contributor to, not causation of mental disorders• Impact of attachment disruption or trauma crosses

domains of behavior, mood, development delay, thought and social interaction- no one diagnosis will do

• Mind- body mosaic of concerns/targets for treatment

• What diagnoses are commonly used today?Anxiety NOS DysthymiaOppositional Defiant DisorderAdjustment Disorder to Posttraumatic Stress DisorderReactive Attachment Disorder

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Reactive Attachment Disorder (IDC 10 Code F94.1)

Essential Features:•absent or grossly underdeveloped attachment between child (at least age 9 months ) and caregiving adults•Can form selective attachments, but due to serious social neglect, fail to show behavioral manifestations of selective attachments, such as don’t seek caregiver for comfort or protection.•Diminished or absent expression of positive emotions during interactions with caregivers•Emotion regulation capacity is compromised- Functional impairments across many early childhood developmental domains•Associated with social neglect, yet occurs in > 10% of children in foster care/institutions•Use with caution in children over age 5

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Disinhibited Social Engagement Disorder (F94-2)

Essential Features:– Pattern of behavior- culturally inappropriate, overly familiar

behavior with relative strangers- violates social boundaries– Diminished or absent checking back with adult caregiver

after venturing away– Willingness to go with unfamiliar adult with minimal

hesitation– History of insufficient care from social neglect or deprivation

or repeated change of caregivers or reared in institutions that limit opportunity to form selective attachments

– Rarely seen in clinical settings- occurs in 20% of severely neglected children

– Older children- see inauthentic expression of emotions & indiscriminate behavior with peers in adolescence

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Explaining RAD to a teen client• There are 2 types, some avoid being close to people at all and

some get close way too fast and then move on quickly to new people, never staying close for too long

• Early exposure to abuse, neglect or too much stress on your developing brain shaped the way your brain was set up to take in and process information.

• You likely have an enlarged “alarm system” in your brain that says danger whenever you feel strong emotions

• It is hard to hold onto problem solving parts of your brain when you feel stressed

• You don’t know how to relax into being with another person . It does not feel safe, joyful or calm to be with someone who counts.

• For kids who had predictable safe caregivers, hearing “no” acts as a break in the brain inside. For you, “no” can bring a feeling of powerlessness and a need to fight, run or disappear.

• Part of you is still learning things little kids learn like calming yourself down when frustrated, how to reflect and talk to yourself about what to do next, read cues of others socially and how to enjoy making others feel good

• RAD is not permanent- Your brain can take in new ways of thinking and feeling about being in close, lasting relationships in ways that feel good and safe- it just takes a lot of repetition for the brain to know this

Engaging the Attachment System for Change

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The Mindful Adult

• Think differently about this child. There is no absolute truth in how to see a situation. Compliance to adult is not the ultimate goal.

• Accept piece of truth in each point of view

• Be willing to sit with uncomfortable feelings of child and of yourself. Feel teen’s pain.

• Cultivate a “Wise Mind”- • Meditation- Present Moment-

Breathing

Helping Residents with Attachment Trauma Heal in Our Homes

• Clients need safe relationships with someone who can do PACE (playful, accepting , curious, empathic) and keep them safe

• Clients are supported to Regulate their Bodies and Emotions• Clients can Reflect on and Tolerate own Experiences• Clients can feel Competent

• Clients can to make sense of their struggles and see a future for themselves

• If our clients are chronically acting out or misbehaving, they are attempting to communicate to you that they are unable to handle their overwhelming internal stress themselves without your help.

• The repetition of two things can change the brain:– Positive relationships – Positive environment

Creating Safety

•First Staff - Now the Resident •Dance - follow – lead – follow, follow, lead•Connect: read their cues•SPACE : Structuring Playful

AcceptingCurious

Empathic

Attachment’s Purpose- Regulation of Emotion with Felt Security as Goal

• Caregivers need to anticipate times when child’s emotions become dysregulated.

• Seek to reestablish a moderate level of emotional arousal in child (co-regulation), and then . . .

• Rejoin with the youth through reviewing what happened and what skills are needed to manage arousal differently, next time.

Attunement

• Need 15 positives for each time say “no”

• Playful, curious exchanges connects left and right hemispheres of brain

• “Feel Felt” – How do for a big old teen?

• Singing, dancing, laughing, fishing, quilting, lotioning, wrestling, touching, building, catching, sitting, watching…..

Relational Regulation -the positive feedback loop:

Adult focuses on staying in relationship with the child.– Reminds self that the child is scared, not angry– Remembers that the fear is about ourselves, NOT the child. – Remembers that 95% of the time, safety is not the real issue.

It is our own fear that drives an aggressive situation into a dangerous situation.

– Remembers that fear makes everyone become more demanding, rigid, controlling

– “It is Ms. B to you” -Stay with, through many trials

Matched Intensity

• Feel and show that you get teen’s disappointment with tone of voice and body

• Show teen how to come down off of intense emotion

• Do the unexpected (from the fight)

• Compliment, hug, eat cookies

• Be a “sportscaster” Notice moment by moment in concrete language

• Reframe- address the core emotional issue

How can your housing setting space be co-regulating?

• Sensory stuff- touch, smell, see, taste

• Comfort cubbies- placed of refuge

• Yoga moves• Mindfulness• Music• Movement• Schedule- predictable,

visible

Practical Ideas

• Cool down space with sensory items

• Staff generate list of youth’s likes and dislikes- know triggers

• Pictures in space depict ways youth belongs, participates

• Rituals, Routines• Dance /Music/knitting• Safety crew

• Structure• Nurture• Engage • Challenge

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Therapy Interventions Clinic, Home or SchoolBuilds a Bridge between Teens and Their Key People

• Practice attachment with adult resource people

• “internalize a thermostat for regulating stress through attunement”

• Self Regulation “tolerating waves of feeling so can act on own behalf”

• Mentalizing- “seeing self from outside and others from inside”

• Why

• Am

• I • Talking?

Power of Story TellingAdolescent Journey toward Self

• Resilience- inward Communion and external Community

• “Nestled Russian Doll” • Coming of Age Ritual• “Suffering Skin”• One minute narratives• Collages- parts of self into whole• Raps- Spoken word

Real Life Outcomes

• Teen knows she can be both dependent and independent without losing core relationships

• Fear and anger are smaller, hope and joy are possible• Teen can accept nurturance, protection and challenge

from key adults in his life• Teen knows that she belongs and has worth through

connection to at least one other• Teen can make sense of past loss/trauma experiences,

through knowing what strategies he used to survive and being aware of how he can do relationships today, in safer times

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Potential Treatment Goals-TeenReducing Fear–Increase capacity to accept adult help and care–Allow adult to help manage strong emotions (regulation)–Learn to accept feedback and redirection from caregiver–Has reliable ways to reduce stress in face of threatShifting Thinking–Select key adults for help with problem solving–Practice showing awareness of how peer’s thoughts or feelings can be different from ownPromoting Social Belonging•Increase ability to “play” in reciprocal manner•Able to stick with a social activity through successes and set backs

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Potential Treatment Goals- Parent(thanks, Carol Siegel)

• Read child’s intentions in the moment to help child learn her own mind.

• Respond to child’s very slight overtures to help him feel effective.

• Verbalize for child what she is feeling or wanting as much as you can tell.

• Read child’s nonverbal communication so child learns to connect behavior and emotion/intention

( “You moved away, maybe you need space?”)

• Narrate child’s experience and include a solution.• Prepare child for emotional experiences (“We are going

to the DMV and you might be bored, what should we bring?”)

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The capacity to care, share, listen, value and be empathic develops from being cared for, shared with, listened

to, valued and nurtured. Dr. Bruce Perry