attachment disorder the childrens center home反应性依恋障碍的儿童中心的家课件

Reactive Attachment Disorder: Assessment and Effective Treatments for Foster and Adoptive Children Douglas Goldsmith, Ph.D. Executive Director The Childrens Center What is Attachment? n“To say of a child (or older person) that he is attached to , or has an attachment to, someone means that he is strongly disposed to seek proximity to and contact with that individual and to do so especially in certain specified conditions.” Bowlby (1988) Attachment Behaviors nApproach the caregiver nCrying nSeeking contact nMaintaining the contact nThe number of attachment behaviors will vary with the degree of the perceived threat in the environment Weinfield et al (1999) Secure Attachment nThe caregiver is perceived as a reliable source of protection and comfort Secure Attachment nWhen I am close to my loved one I feel good, when I am far away I am anxious, sad or lonely nAttachment is mediated by looking, hearing, and holding nWhen Im held I feel warm, safe, and comforted nResults in a relaxed state so that one can, again, begin to explore Holmes (1993) Secure Attachment nPromote exploration of the environment nExpand mastery of the environment n“I can explore with confidence because I know my caregiver will be available if I become anxious.” nThe infant gains confidence in his or her own interactions with the world Weinfield et al (1999) Disorganized vs. Attachment Disorder nDisorganized Attachment: describes an insecure but selective attachment nAttachment Disorder: the failure to show selective attachment A pervasive disturbance OConnor & Zeanah (2003) Developmental Perspective n“The quality of a young childs attachment to a caregiver is a risk or protective factor for development of psychopathology.” Zeanah & Smyke (2005) Clinical Perspective n“The attachment relationship may be so disturbed as to constitute an already established disorder.” Zeanah & Smyke (2005) Reactive Attachment Disorder nDSM-IV nThe essential feature of Reactive Attachment Disorder is markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before age 5 and is associated with grossly pathological care. Core Features nThere must be evidence of grossly pathogenic care nThe disturbance must be evident across situations and across relationships OConnor & Zeanah (2003) Pathogenic Care nPersistent disregard of the childs basic emotional needs for comfort, stimulation, and affection nPersistent disregard of the childs basic physical needs nRepeated changes of primary caregiver that prevent formation of stable attachments Disinhibited Type nPredominate disturbance in social relatedness is indiscriminate sociability or a lack of selectivity in the choice of attachment figures. Indiscriminate Behavior n“The terms indiscriminately friendly and indiscriminate sociability imply more than is actually known about the nature of the childs behavior” OConnor & Zeanah (2003) Inhibited Type nPersistent failure to initiate and to respond to most social interactions in a developmentally appropriate way. What About Older Children? nDefining attachment in older children. nAge of onset must be 5 years of age or younger. nMultiple caregivers or pathogenic care should be noted on axis IV. nRelationship can still be focal point of treatment. Research nRAD has been described formally in psychiatric nosology for 25 years nFewer than one dozen studies involving only seven samples of young children Zeanah & Smyke (2005) Assessment n“No gold standard exists for assessing attachment disorders, and very little information is available on the convergence of information from alternative assessment methods.” OConnor & Zeanah, 2003 Treatment n“No treatment has been shown to be effective for children with attachment disorders.” OConnor & Zeanah 2003 Assessment n“The key to assessing attachment rests in determining how an infant organizes attachment behaviors to balance the need for protection and comfort with the desire to explore the environment.” Weinfield et al (1999) Assessment Worksheet nHelps organize information obtained from observations and interviews nHelps determine treatment needs nAssists with planning attachment based interventions Secure Base Behaviors nChild explores the environment freely while checking in with the parents as necessary Note childs affect Bright and engaged? Anxious? Hypervigilant? Does child readily explore? Does child make use of toys? Does child share positive experiences with the caregivers? Secure Base nChild seeks contact with the parents for comfort when anxious, frightened, or hurt Who initiates the contact? Is the contact soothing? How long does it take for the child to soothe? Is the caregiver sensitive to childs needs and cues? Secure Base nInfants and Toddlers: Does the child visually check in with the parents to gain reassurance about contact with the examiner? Does the child demonstrate physical withdrawal at least momentarily when the examiner attempts outreach? Secure Base nDo the caregivers demonstrate a sense of pride in the childs exploration? Are they responsive to childs delight in exploration? Are they facilitating play with an appropriate affect? Insightfulness nThe parents are able to share examples suggesting insight into the childs motives, thoughts, and feelings behind a range of behaviors “ Can you give me an example of a time when your childs behavior was upsetting to you? What do you think might have been going on in his/her head? How did these behaviors make you feel? Insightfulness nThe parents are able to appropriately reflect the childs feelings: Watch for cues during your observation Ask how the caregivers responded the last time the child felt frightened, worried, or anxious Insightfulness nThe parents show sensitivity to the childs needs for affection and respond both to the childs needs for comfort as well as to the childs desire to terminate physical contact Frightening Behavior nThe parents have protected the child from exposure to domestic violence or other environmental variables that would create fear or anxiety for the child Protection from violence and excessive arguing Protection from frightening movies Frightening Behavior nThe parents avoid engaging in frightening behavior e.g. purposely scaring the child, physically harassing the child despite the childs pleas to stop the behavior Parents avoid threatening to leave or abandon the child Protection nThe parents establish appropriate boundaries with extended family members and strangers regarding contact with the child Supervision issues Parents exhibit an awareness of need for vigilance around unfamiliar people and situations Protection nThe parents provide a sense of safety in the home by not allowing persistent physical or verbal attacks from siblings, peers, or other people present in the home Caregivers establish and adhere to limits on sibling rivalry behaviors Caregivers process verbal attacks between siblings Protection nSeparations from the child for more than several days have been kept to a minimum Have the parent describe the childs behavior upon their return home Structure and Developmental Guidance nThe parents are aware of, and are responding to, the childs current developmental needs Structure and Developmental Guidance nThe parents expectations of the child are neither overwhelming or too restrictive Be particularly sensitive to children who appear older than their years Be aware of parental expectations of the oldest child Structure and Developmental Guidance nThe parents are able to set and maintain appropriate limits during the session and report appropriate limits in the home Are the parents willing to assert their authority? Are caregiving decisions abdicated to the child? Summarizing Your Findings nStrengths of the parent-child interaction nConcerns about the parent-child interaction Summarizing Your Findings nWhat are the attachment/ relationship needs of this particular child? nWhat skills do the parents need to develop? Attachment Based Interventions nSecure Base May need to address underlying issues around parental unavailability to the child vIs the childs behavior so out-of-control that the parent is unable to find enjoyable one-on-one moments? Plan behavioral interventions to increase cooperation to parental requests vDoes the parent find parent-child time enjoyable? Attachment Based Interventions nSecure Base Use precision commands to help the parent develop positive behavioral control vStop the coercive cycle vUse time-limited time-outs to gain compliance vReinforce all compliant behaviors vPositive practice vEncourage the parent not to give up positive reinforcers prematurely Attachment Based Interventions nSecure Base Decrease oppositional battles around: vToileting Assist with toilet training or encourage the parent to relax anxiety around toileting accidents vEating Stop discussions about quantity of food or insisting that the child increase their food repertoire vSleeping Encourage the parent to help the child regulate anxiety around sleep. Develop a bedtime routine Attachment Based Interventions nSecure Base Help parent learn to give warnings around transitions and brief separations Increase predictability of the environment Increase reliability of parental availability vThis is important particularly for the non- custodial parent vEvaluate the possibility of telephonic or electronic communication Attachment Based Interventions nSecure Base Develop nurturing skills Help the parent learn to be an “ideal grandparent” vAnticipate the childs needs vProvide physical comforts vPlan surprises so the child knows s/he is thought about even when absent vIncrease sensitivity to cues Attachment Based Interventions nExploration Help the parent develop age appropriate expectations Carefully evaluate and develop appropriate parental supervision Assess joint pleasurable activities and develop a list of pleasant activities Attachment Based Interventions nExploration Examine the parents ability to “let go” Develop plans and support the parent in managing “conflict free” separations by waiting until the child is comfortable in a new environment Attachment Based Interventions nExploration Teach the child “checking in” behaviors vAlways keep the caregiver in view vUse a timer to help the child develop checking-in skills Attachment Based Interventions nEmotional Regulation Teach the parent to use “Time-in” vRemain available during emotional outbursts vOnly move away if child attempts physical attacks vConstantly reassure child that, “As soon as you calm down, Ill help you fix it/ figure it out” vIf attacks persist state, “Ill be in the next room so I can stay safe but as soon as I hear you calm Ill be right back” vDevelop deep breathing and self-soothing skills Attachment Based Interventions nEmotional Regulation Work on acceptance of physical contact vHelp child make self-contact rather than other- contact to soothe self Avoid direct “no” and instead fantasize what it would be like if the child could get all of his/her needs met Write down and post the desire to be satisfied at a later d