How to cope in a world without subtitles.

Deceil L. Moore, LCSW, NADD-CCMischa Staton, MA, NADD-DSP

ATTACHMENT ISSUES AND ID– FOR DSP’S

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Deceil L. Moore, LCSW, NADD-CC

Mischa Staton, MA, NADD-DSP

GOALS FOR TODAYClick icon to add picture

• Understand what Attachment is and how important it is

• Understand what Attachment Disorders/ issues are

• Understand how Attachment Disorders develop• Understand the implications of unresolved

attachment issues• Understand how to respond to persons with

attachment issues in order to help them grow and thrive in positive ways

• Recommit to those we care for and about and help them to overcome the challenges they face because of attachment issues

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Remember: Many, many different ways to respond to any one situation. Examples presented are not “recipes” just one set of circumstances under which someone adapted with attachment challenges.

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Attachment Disorder

What Do You Think of when You See Those Words

Click icon to add pictureReactive Attachment Disorder:

– Persistent failure to respond to interactions in a developmentally appropriate way

– Diffuse attachments (indiscriminate social ability w/ marked inability to exhibit selective attachments

– History includes: persistent disregard for child’s emotional needs/physical needs or repeated changes in primary care giver

Have learned to distrust that the world will provide for them

PEOPLE WITH ATTACHMENT ISSUES. .

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And what becomes of a child who becomes an adult without some help with attachment issues?

Possibly traits of:

Dependent Personality Disorder

Borderline Personality Disorder

Anti-Social Personality Disorder

Anxiety

PTSD

Depression

Narcissistic Personality Disorder

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Kim—frightened, somatic complaints, frequent talk and some gestures of harming self, has personal dreams—makes plans does not follow through

Example: Kim:

Mild delay, some anxiety

Father chronically ill,

Mother has some symptoms of mood disorder

Pattern of one parent or another in the hospital frequently, person left struggled to care for themselves let alone her

When older sibling leaves, “about killed mom”

ATTACHMENT THEORY

• John Bowlby wrote “Attachment and Loss” in 1969; Mary Answorth, Cindy Hazan, Phillip Shaver and many others

• The idea that quality of attachment to primary caregivers has long lasting impact on emotions and behavior; impacts behavior in adults as well

• Laws/policies have been changed in response

WHAT IS ATTACHMENT?

A reciprocal, enduring, emotional and physical affiliation between a child and a caregiver. It is the psychological connection between people that permits them to have significance to each other.

HEALTHY ATTACHMENT CYCLE

Parent Response

Need Fulfillment

(Not)

Child in Need

Progress toward Trust (Not)

TRUST VS MISTRUST

• Attachment comes in cycles—– Think of a baby—one time of being fed not

enough but several, leads to calmness

– After several successful completions of the cycle, the child begins to trust

– After several unsuccessful completions of the cycle, child begins to adapt or have difficulty

(anxiety, depression)

WHEN CHILDREN LEARN TRUST--

They can trust and cope, less likely to act out or panic

• If Caregivers are a secure base and a safe haven– Support, welcome, comfort, protect, enjoy

• Children—and those with attachment issues can:– Safely explore the world– Seek interactions, delay interactions– Give information– Assist in organizing the child’s

feelings/reactionsThey turn into people who trust. . . .

ATTACHMENT/TRUST CYCLE NOT SUCCESSFUL

* Begin to not expect, give up hope about needs being met*Might begin to figure out ways to meet the needs themselves (ODD)*Probably have difficulty developing empathy*Might have difficulty being independent*Might have difficulty relating to anyone*Might have difficulty making sense of how they feel/what they need and do*May have difficulty expressing what they need*This can lead to more difficulties relating

ATTACHMENTS HELP WITH

1. Developing and maintaining trust2. Conscience Development3. Developing healthy relationship4. Developing Identity and self-esteem5. Regulating feelings6. Developing language7. Developing brain structures for later use8. Organizing the nervous system

CAREGIVER’S ROLE IN ATTACHMENT

• Be Accessible • Be Responsive• See the beauty• Enjoy the person• Believe in them

CHALLENGES TO POSITIVE ATTACHMENT FOR PERSONS WITH ID

• Extended stay in ICU• Lack of reciprocity (sensory integration,

cognitive challenges, physical challenges)• Caregiver grief or guilt• High level of family stress• A child with disabilities may have difficulty

responding to the caregiver in the attachment cycle; attachment might be too much at times

• Frequent moves and/or change in caregiver

• Little relief for care givers, increase pressure on care giver for attachment

• Fear of attachment related to repeated surgeries or health concerns

• Unease/feelings of incompetency with ID/challenges

• Misunderstanding of appropriate expectations can lead to abuse/neglect

• Sometimes or told. . . “he’ll have to but put somewhere”—can affect believe that attachment can/will/should occur

YEARS LATER—LESS APPARENT BUT SYMPTOMS GIVE CLUES

EXAMPLE: BELLA

• Background• Sensory challenges—• Some academic challenges• Behavioral issues arise (aggression, verbal

aggression—seemingly without antecedent)

CATEGORIES OF ATTACHMENT CHALLENGES

• Avoidant/inhibited/unattached

• Lots of movement not much connection-• Unaware of what is going on for others-• Difficulty communicating and with emotions-• Self absorbed?• No clear connection-

• Touch??

• Anxious/disinhibited

• Lots of anxiety, especially about being abandoned, left alone

• Avoid anxiety triggers (makes excuses)• Will connect indiscriminately• -Come here/get away

• Disorganized

• Rapidly shifting emotions• Aggressive in response to fears or in response to

many things• Does not typically show remorse

• Example: Bella (behavioral examples)

But the need does not go away, just because you don’t trust. . . . “I am desperate to be close to you. . . But it scares me to death.”

Image to help you understand. . . . RAD

When you get close. . . . You see lots of things like this surrounding the water. . . . . . What Do You Do???

HOW CAREGIVERS OFTEN REACT TO BEHAVIORS RELATED TO ATTACHMENT…

• Get frustrated! Get scared!• Take it personally and see themselves as a

failure• Get told by professionals that they are

“making it up”• Eventually, give up -

– Placement is lost– Person stays but no attachment develops

• Become dysregulated – ????????????????????

THE DO’S IN RESPONDING. . .

• Understand-this is scary• Reduce changes in relationships as much

as possible (placements, therapists, etc.)• Find the “place in the room” you can

always stand—”I care about you. I want to help. I can’t let you hurt you or anyone else.”

• Have appropriate boundaries you are willing to enforce

• Do LOTS of bonding activities

DON’T TAKE IT PERSONALLY. . . .

• Individual is working in a world whose assumptions are different from yours. . . .

• Often individual get very afraid when they start to feel comfortable with someone

• They often work to chase you away so that they’ve had control of you leaving. . . It is less painful that way.

• You can help by: Believing that everyone wants to attach – they just might not know how

• It also helps to: Be patient. Don’t give up. Don’t personalize.

RESPONDING TO BEHAVIORS

• Be firm and clear• Have appropriate boundaries• Express that you care• Support that he/she has a choice is choosing• “Join” with them—be disappointed in outcomes

with them, be excited about rewards with them• Time In as opposed to Time Out• Help them see outcomes as related to choices

WHAT DO YOU MEAN?

• Situation: (In response to a new caregiver) “No! This is so stupid. I don’t need this! “ Stomps out, later calls saying thinking of killing self

• Possible responses:• I sometimes don’t like meeting new people either.• You sound very upset. I get that. What can I do

to help you?• You are so strong and have adapted already so

much. It does feel unfair. You have choices. I would be willing to talk through those with you.

PRACTICE. . . . .

• 1) Talk of robbing banks and killing people

• Panic and go to extremes if mild indication of changes especially in care givers

• “You are the only one I can trust.”

• Gives 2 cars away that is still paying on

GOOD NEWS!!• Attachment is not an event—it is a process.

• Any time that you are able to participate in an attachment activity together that completes the cycle, you have moved one step closer in helping the child heal.

ATTACHMENT TALK

• I want to help. . . . • I know that you are smart and can make good

choices. I want to help.• I am excited about what it will be like when

you. . . • Shoot! I’m disappointed that that won’t work out

now. What do you think we should do?

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Helpful Attachment Activities

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We can strengthen the therapeutic relationship by doing some of these things together within appropriate boundaries. . .

We can help bring further resolution of issues by helping important people in their lives do some of these things with the individuals with attachment issues

***** red asterisks mean that these can be done in the therapeutic relationship

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Increasing Eye ContactMaximizing TouchMoving With Your ChildNurturing Through FoodEnhance CommunicationGetting Warm and CozyJust Have Fun

Click icon to add pictureHave Fun• Laugh with your adolescent about things that, at first,

shouldn’t be funny (teacher fell out of chair but wasn’t hurt)*

• Make something durable together*• Cheer for the same team*• Tie-dye a shirt for everyone in the family• Color with your child*• Complete a jigsaw puzzle together as a family project*• Buy a paper crown. Take turns wearing the crown.

When you wear it, no chores for you that day.• Agree to alternate serious talk with “fluff” talk*• Buy and wear matching t-shirts• Blow bubblies*

Click icon to add pictureGet Warm and Cozy• Make or buy a soft, warm blanket to use while watching

television, reading, etc

• Put his gloves and scarf in the dryer for a few minutes to make them warm. He’ll go to school with a comfy feeling.

• Make a safe place for them* (let them change things in the office)

• Tuck a blanket around the child in the car on a cold day.

• Pitch a tent in the back yard and get in with the child.

• Steam up the bathroom and then everyone draw on the mirror.

• Offer tea/coffee/hot chocolate-go and get it form them, remember how they like it*

• Talk about something you have in common for a few minutes*

Click icon to add pictureEnhancing Communication• Read the funnies together on the couch• Listen to and learn the individual’s favorite song.

Teach him one of yours• Pick a book and read parts of it together every day. (A

Safe Place for Caleb)• Make a list together (famous rabbits, superheroes,

candy bars)*• Tell the individual you need help with something and

let them participate.• Make a life book with the individual. Let them

interview folks and help research for it. Share stories .*

• While waiting for an appointment, make a bet on the color of the professional’s tie or shoes. Celebrate whoever wins*

• Trace a shape on individual’s back with your finger. If he guesses the word, he gets a point.

• Really listen*

Click icon to add pictureNuture Through FoodServe a banana split for dinner. For no reason. Just because. Just once.

Buy a fancy plate at a garage sale. Serve the ind meals on it.

Buy some M&M’s together. Sort them by color. Eat them together. (or talk about what candy you like or games you play with food*)

Give and honor choices *.

Serve the ind something special—i.e. pumpkin spice latte today*

Have a tea party. Trim the crusts from sandwiches and cut into triangles.

Click icon to add pictureMove Together• Toss a ball or beanbag*• Blow bubbles. Chase them around and pop them.*• Fly a kite.*• Catch fireflies, then let them go.• Buy sidewalk chalk and help the ind draw a mural.*• Buy balloons. Blow them up and play a balloon

chasing game.*• Play badminton*• Make a snow sculpture. Put water in a spray bottle,

add food coloring, and spray the sculpture.• Swing together.*• Go for a ride in the country• Have an Easter egg hunt in the summer• “Chase Rocks” at the ocean

Click icon to add pictureMaximizing Touch• Share a delightfully smelling lotion on you and have

him reciprocate. Talk about what smells you like and what you have in common. *

• Offer appropriate touch (hand hug, side hug, display appropriate hug etiquette, pat on the back, arm touch)*

• Sit on the same side of the table and put a puzzle together.*

• Play tag*• Sit together and look at a magazine or book together*

Click icon to add pictureIncreasing Eye Contact• Get a Group photo taken with everyone dressed the

same. Hang it prominently in the home and frame one for each child’s room.

• Play Peek-a-boo or “I spy” and follow where each other are looking. *

• Participate in face painting. • Look at each other and name the ways you are alike.*• Put a sticker on your face right between your eyes.

Don’t comment on it at all. The ind will look at you and laugh—eventually.*

• Talk about applying make up or tying a tie together, demonstrate as you go*

• Really look at the ind and appreciate things about him/her*

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What Helped with Bella

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Brisch, K.H. (2002). Treating Attachment Disorders: From Theory to Therapy. New York, NY. The Guiliford Press

Keck, G.C. & Kupecky, R. (2009). Parenting the Hurt Child. Colorado Springs, CO.: NavPress

Chara, K.A. & Chara, P.J. (2005). A Safe Place for Caleb. London, NJ: Jessica Kingsley Publishers

Cohen, J.A.; Mannarino, A.P; Deblinger, E. (2006). Treating Trauma and Traumatic Grief Children and Adolescents. New York, NY. The Guiliford Press.

Psychologist World and Partners. (2014). Attachment Theory - Developmental Psychology - Psychologist World. Retrieved from http://www.psychologistworld.com/developmental/attachment-theory.php