Friday, January 17, 2014

Attachment Explained

John Bowlby published his theories on attachment in the 1950’s.  They took some time to catch on, especially in the child welfare arena.  Attachment, Bowlby said, is the relationship that develops between child and parent.  More basic than love, it is essential to survival.  Attachment sets the stage for functioning in the world.  Another word used for attachment is bonding; attachment is the noun, bonding is the verb.  Attachment is a one-to-one and directional relationship, from child to parent.  We are not attached to our family.  We are attached to each member of our family in individual and unique ways.  There need be no competition for attachment because there are few limits to the number of relationships we can establish, each of different quality, some closer, some distant, some comforting, some contentious.  Each adult drives this connection primarily through the commitment and care provided the child.  Attachment is a neuro-bio-psycho-social interaction that forms the template for all future relationships.  So attachment is driven by and subsequently drives brain, biological, psychological, and social functioning.  It is a brain-based connection in that, when we are building attachment, we are forming new brain pathways.  The “prime time” for attachment is conception to the first three to four years of life.  This is probably the most startling point for parents of traumatized children both because the original abuse may have happened during this attachment period and because that window of opportunity seems to have closed.  Yet we know the brain is a malleable organ capable of growth until death.  So, we hold out hope that we can change the brain through interaction and heal the child through relationship.
            In the simplest terms, attachment is formed through the arousal/relaxation cycle.  As an organism and species we have basic needs in order to stay alive.  Infants need, at basic, nourishment, elimination, interaction, soothing, and sleep.  The need causes a physiological discomfort or arousal in the infant that is usually expressed in crying.  While attachment is directional and driven by the primary caregiver, it is also a reciprocal relationship.  The infant’s role is to make his or her needs known to the extent possible.  When the caregiver reads the child effectively and meets the need for food, clean diaper, attention, and soothing, the infant’s biological and psychological responses are relaxation until the next need appears.  Of course, in early infancy through toddlerhood, the needs are nearly constant.  If the primary caregiver is able to meet the needs in a “good enough” way, healthy or secure attachment forms.  As important as consistent care is the way in which it is delivered.  Infants take us in through all five senses.  Our body language, demeanor, intent and tone are as important to attachment as food and diapers.  The attachment figure brings comfort in its presence and distress in its absence.  The essential ingredients, then, are basic needs, physical and emotional distress, an expression of discomfort, an appropriate reading of the arousal, and an adequate response that meets the needs resulting in relaxation. 
            This means that “distress” is necessary to secure attachment.  The body, if it is healthy, has the ability to signal need through discomfort.  It is not always the most pleasant experience, especially for stressed out parents, but we need the baby to cry.  This begins in utero as the fetus is forming and the womb and the umbilical cord deliver basic needs in the environment of the mother’s body.  We will talk about pre-birth attachment insults later.  But in healthy pregnancy birth it self is the first major stress of the child’s life.  It is a literal separation from the mother’s body and constant care.  According to Daniel Siegel, the infant experiences birth as a life threatening event.  From this point on the new infant begins to develop coping strategies around separation from mother.  Years ago, and sometimes still in the case of caesarian births, the infant is removed from the mother at birth to be cleaned and weighed and cared for by others.  Nowadays, as you can see in the video from the First Five Years collection, we quickly respond to this distress and repair this break by bringing the newborn directly into the waiting arms of the mother.  We will come back to this theme of break and repair as we talk about parenting.
            If repeated successful completion of the arousal/relaxation cycle leads to secure attachment, then frequent interruptions in the arousal/relaxation cycle lead to compromised attachment.  Instead of breastfeeding or formula, hunger is met with unsatisfying water, Kool Aid, or nothing.  Diapers go unchanged and painful rashes develop.  Medical conditions go unchecked.  The need for attention is met with anger or ignored.  The child who seeks soothing is on his own if not physically assaulted.  Even if the care is adequate, it is delivered with little commitment or enthusiasm if not down right contempt and resentment.  In any case, the child is left in a constant state of chronic stress.  This is the kind of psychological and physiological stress that does not go away.  The causes and reasons are many; lack of education, mental illness, poverty, substance abuse, and family discord.  Often parents manage to meet the needs of their children despite struggling with mental illness, substance abuse, and family violence, and do so with determination and support.  However, many children come to the attention of child welfare services investigating abuse and neglect.  Some half million children are subject to the interventions of the U.S. child welfare system.  Parents are offered services to overcome their problems while their children are in foster care.  While the parent-child relationship is of concern, it is not generally the target of intervention even though it is the most important measure of child safety, well-being, and permanency.

   Children often enter the child welfare system during the first three years of life interfering with the development of attachment.  If they enter the system after the age of three the attachment pattern has generally already been established.  Certainly, many children have developed secure attachments before their parents are overwhelmed by drugs and conflict.  Then, the intervention of the system itself in the form of multiple caregivers and multiple placements in foster care can cause compromised attachment.  This is in contrast to multiple caregivers among various cultures.  In many families, mothers, grandmothers, older siblings, aunts and uncles, and friends of the family all share in the care of children.  The difference between this family style and foster care is that the caregivers do not change.  Despite wide cultural differences in parenting styles, what most cultures have in common is that the life of a child is marked by consistent care and routine.



Monday, January 13, 2014

Attachment Trauma

Donald and Harold are examples of children who have been exposed to attachment trauma.  Starting before they were born while their fetal brains were developing, their mother was unable to make a commitment to them and her pregnancy that would result in good pre-natal care and a safe environment.  She is on the run, and they are at risk. Thus they are born prematurely already having experienced a series of insults that could have jeopardized their lives, read "threat of death".  Then they suffer the loss of their mother and her daily consistent care.  Remember, because infants do not have "object constancy", that is the ability to hold the concept of a person or object in their memories when the person is not physically present, they suffer the loss of a primary caregiver as similar to a death.  Certainly, another caregiver like a grandparent can mitigate the disruption in attachment, but it requires constant consistent care.  For Donald and Harold this was obviously interrupted if child welfare services was concerned enough about their safety to make repeat visits to investigate. 

     Then starts the second level of attachment trauma, the introduction of multiple caregivers starting with foster parents and then their adult sister.  With their sister they are exposed to traumas of commission as well as omission.  To be certain, with their grandmother, foster parent, and sister there were likely many occasions when they felt safe and loved, but it never lasted.  Their sister's substance abuse leads to unmet needs; gnawing hunger, untreated illness, lack of developmental play, as she cycles between intense interaction and depressive withdrawal.  A note: hunger at this age can cause serious help problems and even death, and feels like it.  The boys experience adults as highly unpredictable.  The relationship violence in the home leads to intense anxiety and fear, trouble sleeping, and anger in twins barely two years old.  No wonder they started developing some really interesting survival skills; watchful hyper-vigilance, sneaky food hoarding, and the ability to either tune out or run from danger.  These are the still small children who stroll into the first, second, and third foster/adoptive homes.  Despite their best intentions and training none of these subsequent parents can offer consistency from one home to the other.  This is the third level of attachment trauma, no one sticks around long enough to trust. These children are in survival mode.

     At this point the boys move into the next home as if they are traveling salesmen.  Full refrigerator, check. Television with cable, check. A place to park my carry on bag, fine.  Someone at the front desk to keep things running, ok. Chores?  "Wait a minute, I don't clean my own room!" Responsibilities? "This isn't my house!" Say thank you? "You're getting paid for this!"   Here's where all of those nifty survival skills become symptoms of some serious mental health disorders.  The new parent repeats herself with her voice rising in pitch each time.  The new teacher complains that the boys do not follow directions or complete their homework.  It's sounding a lot like Attention Deficit Hyperactivity Disorder.  One boy refuses to turn off the television, and the other refuses to go to bed.  When the new parent removes privileges or says no, one boy flies into a rage and the other ignores it.  It's sounding a lot like Oppositional Defiant Disorder.  When stuff starts disappearing or getting broken and the teacher sends one boy to the principal's office, we're heading toward Conduct Disorder.  Throw in two hour tantrums alternating with sullen crying bouts, and Bi-Polar Disorder looks like a real possibility.  "These boys need medication."  "Not taking it." "You need therapy!" "I won't talk." "These children have to move!"  "Fine, I'm checking out anyway."

     Here's where the situation could go either way.  We could begin focusing on the boys' behavior, putting them in a room alone with a therapist, exploring their "feelings" and offering them rewards and punishments for going with the program.  The new therapist would report some success each session.  But the parent would report no change at home.  Or, we could begin understanding the behaviors as symptoms of a much more complicated diagnosis.  You see, if you put these two boys in a house with no parent, they would probably do just fine.  Ok, like any nine year olds, they would eat cookies for breakfast and forget to flush the toilet.  But they probably wouldn't have these huge blow-ups, even with each other.  The problem is... the parent.  The nice parent is scary.  The predictable parent causes anxiety.  From the earliest age the most primitive parts of their brains are primed to fear parents, to fight care, to flee love, even while their minds tell them they need and want it.  It's post traumatic stress disorder, and the relationship is the trigger.  Like the negative poll of a magnet they are repulsed by attempts to get close to them.  And if, by chance, there is a positive pull, they are unable to break free to function independently.  This is relational PTSD.  The abuse these children experienced happened in the context of what was supposed to be a nurturing relationship.  Now they are in a pretty safe situation, but their brains and bodies don't believe or feel it.  Like soldiers back from the war they are hypervigilant with and distrustful of the person they need the most...the parent.